Systematic Approach to Address Early Pandemic's Diagnostic Unmet Needs.

During the first few months of the global Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) pandemic, the medical research community had to expeditiously develop, select, and deploy novel diagnostic methods and tools to address the numerous testing challenges presented by the novel virus. Integrating a systematic approach to diagnostic selection with a rapid validation protocol in a clinical setting can shorten the timeline to bring new technologies to practice. In response to the urgent need to provide tools for identifying SARS-CoV-2-positive individuals, we developed a framework for assessing technologies against a set of prioritized performance metrics to guide device selection. We also developed and proposed clinical validation frameworks for the rapid screening of new technologies. The rubric described here represents a versatile approach that can be extended to future technology assessments and can be implemented in preparation for future emerging pathogens.

Evaluation of serological lateral flow assays for severe acute respiratory syndrome coronavirus-2.

BACKGROUND: COVID-19 has resulted in significant morbidity and mortality worldwide. Lateral flow assays can detect anti-Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) antibodies to monitor transmission. However, standardized evaluation of their accuracy and tools to aid in interpreting results are needed. METHODS: We evaluated 20 IgG and IgM assays selected from available tests in April 2020. We evaluated the assays' performance using 56 pre-pandemic negative and 56 SARS-CoV-2-positive plasma samples, collected 10-40 days after symptom onset, confirmed by a molecular test and analyzed by an ultra-sensitive immunoassay. Finally, we developed a user-friendly web app to extrapolate the positive predictive values based on their accuracy and local prevalence. RESULTS: Combined IgG + IgM sensitivities ranged from 33.9 to 94.6%, while combined specificities ranged from 92.6 to 100%. The highest sensitivities were detected in Lumiquick for IgG (98.2%), BioHit for both IgM (96.4%), and combined IgG + IgM sensitivity (94.6%). Furthermore, 11 LFAs and 8 LFAs showed perfect specificity for IgG and IgM, respectively, with 15 LFAs showing perfect combined IgG + IgM specificity. Lumiquick had the lowest estimated limit-of-detection (LOD) (0.1 µg/mL), followed by a similar LOD of 1.5 µg/mL for CareHealth, Cellex, KHB, and Vivachek. CONCLUSION: We provide a public resource of the accuracy of select lateral flow assays with potential for home testing. The cost-effectiveness, scalable manufacturing process, and suitability for self-testing makes LFAs an attractive option for monitoring disease prevalence and assessing vaccine responsiveness. Our web tool provides an easy-to-use interface to demonstrate the impact of prevalence and test accuracy on the positive predictive values.

An assessment of temporal, spatial and taxonomic trends in harmful algal toxin exposure in stranded marine mammals from the U.S. New England coast.

Despite a long-documented history of severe harmful algal blooms (HABs) in New England coastal waters, corresponding HAB-associated marine mammal mortality events in this region are far less frequent or severe relative to other regions where HABs are common. This long-term survey of the HAB toxins saxitoxin (STX) and domoic acid (DA) demonstrates significant and widespread exposure of these toxins in New England marine mammals, across multiple geographic, temporal and taxonomic groups. Overall, 19% of the 458 animals tested positive for one or more toxins, with 15% and 7% testing positive for STX and DA, respectively. 74% of the 23 different species analyzed demonstrated evidence of toxin exposure. STX was most prevalent in Maine coastal waters, most frequently detected in common dolphins (Delphinus delphis), and most often detected during July and October. DA was most prevalent in animals sampled in offshore locations and in bycaught animals, and most frequently detected in mysticetes, with humpback whales (Megaptera novaeangliae) testing positive at the highest rates. Feces and urine appeared to be the sample matrices most useful for determining the presence of toxins in an exposed animal, with feces samples having the highest concentrations of STX or DA. No relationship was found between the bloom season of toxin-producing phytoplankton and toxin detection rates, however STX was more likely to be present in July and October. No relationship between marine mammal dietary preference and frequency of toxin detection was observed. These findings are an important part of a framework for assessing future marine mammal morbidity and mortality events, as well as monitoring ecosystem health using marine mammals as sentinel organisms for predicting coastal ocean changes.

Association between red tide exposure and detection of corresponding neurotoxins in bottlenose dolphins from Texas waters during 2007-2017.

Harmful algal blooms produced by the phytoplankton species Karenia brevis and its associated neurotoxin, brevetoxin (PbTx), occur throughout the Gulf of Mexico and have had devastating impacts on co-occurring populations of bottlenose dolphins (Tursiops truncatus), an important marine sentinel species. The majority of documented impacts, however, are from the eastern Gulf of Mexico, with a critical lack of information on the degree and frequency of PbTx exposure in bottlenose dolphins from Texas coastal waters. This study documents PbTx exposure in Texas bottlenose dolphins between 2007 and 2017 and their association with co-occurring K. brevis blooms. PbTx was detected in 60% (n = 112) of the animals tested. Liver tissue samples had the highest frequency of detection (62%), followed by feces (41.4%) and gastric contents (30.4%). PbTx was not detected in urine or intestinal tissue. The concentration ranges of PbTx detected in feces (1.2-216, mean 38.4 ng/g), gastric contents (3.3-1016, mean 158 ng/g) and liver (0.6-52.4, mean 8.5 ng/g) samples were an order of magnitude less than values reported for Florida dolphins for the same sample types. The proportion of dolphins recovered within 4 weeks of a bloom that tested positive for PbTx ('Bloom' group; 75%) was significantly higher compared to those that were recovered 5-8 weeks after termination of a bloom ('Post-Bloom' group; 36%; p = 0.004). The proportion of PbTx-positive animals with no observed bloom association ('Baseline' group; 60%) was also significantly greater than the Post-Bloom group (p = 0.012). No significant difference in proportion of PbTx-positive animals was detected between Bloom and Baseline groups (p = 0.242). No significant differences in liver PbTx concentrations were observed between any pairwise combinations of the 3 exposure groups (p = 0.261). Overall, these findings suggest persistent PbTx exposure for many individuals in these populations, although the health impacts of such exposure are not known.

Explosive exhalations by common bottlenose dolphins during Karenia brevis red tides.

Harmful algal blooms (HABs) such as those produced by Karenia brevis have acute negative impacts on common bottlenose dolphins (Tursiops truncatus) in Florida coastal waters, frequently causing illness and death. However, much less is known about chronic, sub-acute effects on these important sentinel species. This study investigates whether bottlenose dolphin behavior in Sarasota Bay, Florida is influenced by the presence of severe red tide events, focusing on respiratory and other behaviors likely affected by abundant toxin aerosols produced during these blooms. Through focal animal behavioral follows, we observed free-ranging dolphin respiratory behavior, activity budgets, and movement patterns relative to K. brevis abundance in the study area. We compared behavior from dolphins observed during a 2005 K. brevis bloom to those observed during inter-bloom conditions where K. brevis was present at background concentrations. We found that the rate of "chuffing", an explosive type of exhalation, was significantly greater in dolphins observed during the bloom. No apparent effect on respiratory rate, heading change rate or activity budgets was observed. We propose that this chuffing behavior is analogous to symptoms of respiratory irritation observed in humans exposed to such red tide events, and suggest that this may be a type of disturbance response. With an observed increase in both the frequency and severity of HABs, such disturbance responses may have large-scale chronic impacts to the health and fitness of bottlenose dolphins in regions where such HABs are common.

Can mHealth Technology Help Mitigate the Effects of the COVID-19 Pandemic?

Goal: The aim of the study herein reported was to review mobile health (mHealth) technologies and explore their use to monitor and mitigate the effects of the COVID-19 pandemic. Methods: A Task Force was assembled by recruiting individuals with expertise in electronic Patient-Reported Outcomes (ePRO), wearable sensors, and digital contact tracing technologies. Its members collected and discussed available information and summarized it in a series of reports. Results: The Task Force identified technologies that could be deployed in response to the COVID-19 pandemic and would likely be suitable for future pandemics. Criteria for their evaluation were agreed upon and applied to these systems. Conclusions: mHealth technologies are viable options to monitor COVID-19 patients and be used to predict symptom escalation for earlier intervention. These technologies could also be utilized to monitor individuals who are presumed non-infected and enable prediction of exposure to SARS-CoV-2, thus facilitating the prioritization of diagnostic testing.

Utilization of epidermal growth factor receptor (EGFR) testing in the United States: a case study of T3 translational research.

PURPOSE: We examined hospital use of the epidermal growth factor receptor assay in patients with lung cancer in the United States. Our goal was to inform the development of a model to predict phase 3 translation of guideline-directed molecular diagnostic tests. METHODS: This was a retrospective observational study. Using logistic regression, we analyzed the association between hospitals' institutional and regional characteristics and the likelihood that an epidermal growth factor receptor assay would be ordered. RESULTS: Significant institutional predictors included affiliation with an academic medical center (odds ratio, 1.48; 95% confidence interval, 1.20-1.83), participation in a National Cancer Institute clinical research cooperative group (odds ratio, 2.06, 1.66-2.55), and -availability of positron emission tomography scan (odds ratio, 1.44, 1.07-1.94) and cardiothoracic surgery (odds ratio, 1.90, 1.52-2.37) services. Significant regional predictors included metropolitan county (odds ratio, 2.08, 1.48-2.91), population with above-average education (odds ratio, 1.46, 1.09-1.96), and population with above-average income (odds ratio, 1.46, 1.04-2.05). Distance from a National Cancer Institute cancer center was a negative predictor (odds ratio, 0.996, 0.995-0.998), with a 34% decrease in likelihood for every 100 miles. CONCLUSION: In 2010, only 12% of US acute-care hospitals ordered the epidermal growth factor receptor assay, suggesting that most patients with lung cancer did not have access to this test. This case study illustrated the need for: (i) increased dissemination and implementation research, and (ii) interventions to improve adoption of guideline-directed molecular diagnostic tests by community hospitals.

Therapeutic success via targeted approaches and strategic partnerships with clinical laboratories.

The future of personalized medicine and the biopharmaceutical industry may lie in the close interaction between drug developers and clinical laboratories. The output of the Human Genome Project and other basic research into various diseases is generating data on individual variation in the treatment responses of patients; the biopharmaceutical industry and clinical laboratories will be expected to use this information to identify those patients who are best able to respond to a particular targeted therapy. Strategic partnerships between drug companies and clinical laboratories will be the centerpiece of this new era of medical treatment, providing higher-resolution diagnostics as well as more efficacious and safer treatment options.

A comparison of the phenotype and genotype in adenomatous polyposis patients with and without a family history.

OBJECTIVES: Adenomatous polyposis of the colon is often secondary to an inherited mutation in adenomatous polyposis coli (APC) gene, however, approximately one third of patients have no family history of the disease. We studied the phenotype and genotype of adenomatous polyposis in patients without a family history. METHODS: A cohort of 57 unrelated adenomatous polyposis patients were evaluated. Seventeen patients with no family history were compared with 40 patients who had a positive family history of the disease. Family history and medical records were collected and analyzed. Germline APC and Mut Y homologue (MYH) testing was undertaken. RESULTS: Patients without a family history were diagnosed with polyposis at an older age (41 years vs. 32 years) and presenting more frequently with symptoms (76 vs 20, P < 0.05). The number of colonic polyps and frequency of extracolonic manifestation associated with adenomatous polyposis did not differ between the two groups. APC mutations were detected less frequently among patients without a family history of the disease (4 out of 17 vs 25 out of 40, P=0.007), even among those with greater than 100 colorectal adenomas (4 out of 12 versus 21 out of 29, P=0.03). One homozygous MYH mutation carrier (G382D) was detected among the six patients without a family history and without a germline APC mutation who were tested. CONCLUSIONS: Adenomatous polyposis patients without a family history are usually diagnosed with symptoms, and at a later age. Phenotypically, they are similar to those with a family history. However, germline APC mutations are detected far less frequently in patients without a family history. A small percentage of these cases may be secondary to biallelic germline MYH mutations.

Intradural spinal vein enlargement in craniospinal hypotension.

We present a case of craniospinal hypotension in a 45-year-old woman with an associated epidural pseudomeningocele extending the entire length of the spine. The epidural pseudomeningocele was caused by a CSF leak at the T8 level. In addition to typical low-pressure symptoms, the epidural pseudomeningocele caused atypical symptoms characterized by positional thoracic radiculopathy. Craniospinal hypotension was associated with massive cervical epidural venous engorgement, as well as enlargement of the posterior spinal cord vein, which was reminiscent of a dural arteriovenous fistula at CT myelography. Enlargement of the posterior spinal vein is explained by the Monro-Kellie hypothesis, and the spinal analog to enlarged cerebral veins known to be associated with intracranial hypotension.

The effect of passive ultrasonic activation of 2% chlorhexidine or 5.25% sodium hypochlorite irrigant on residual antimicrobial activity in root canals.

Ninety-four single-canal roots were prepared using the step-down technique. Forty-two canals were irrigated with 2% chlorhexidine, 42 canals with 5.25% sodium hypochlorite (NaOCl), and 10 control canals with phosphate-buffered saline (PBS). The chlorhexidine and NaOCl groups were each then equally divided into a final irrigation group and a 1-min passive ultrasonic irrigation group. Canals were enlarged with a Parapost drill. The apical 3-5 mm was covered with nail polish. Canals were rinsed with PBS, dried, refilled with PBS, and stored. At 6 h, 20 microl of fluid was pipetted from each canal and placed into wells on agar plates, which were inoculated with Streptococcus sanguinis. The plates were incubated, and zones of inhibition were measured. Sampling was repeated at 24, 48, 72, 96, 120, 144, and 168 h. Residual antimicrobial activity with 2% chlorhexidine was statistically significantly superior to 5.25% NaOCl with irrigation alone and with final passive ultrasonic activation (p < 0.001). Chlorhexidine experimental groups demonstrated residual antimicrobial activity for as long as 168 h.

The identification of clinically relevant markers and therapeutic targets.

The history of tumor biomarker discovery has been one of limited success. Population based screens are few and of limited clinical usefulness. Biomarkers that are able to segregate patients by diagnosis, prognosis and appropriate therapeutic selection are in great need and will be the basis of the clinical management in the future. This review sets out the challenges inherent in the field of tumor biomarker discovery and the tools that we are using to meet that challenge. It is now possible, using this suite of technologies, to discuss novel tumor biomarkers in terms of a pipeline rather than single unique events in research. The future of clinical oncology management will use markers such as those being identified via these techniques to improve patient care through better diagnosis and hopefully to achieve greater success in treatment by exploiting tumor markers as therapeutic targets.

Hereditary nonpolyposis colorectal cancer in young colorectal cancer patients: high-risk clinic versus population-based registry.

BACKGROUND & AIMS: Early onset colorectal cancer (CRC) is an important feature of hereditary nonpolyposis colorectal cancer (HNPCC). We sought to compare rates of genetically defined HNPCC among individuals with early onset CRC drawn from a high-risk clinic and a population-based cancer registry. METHODS: Probands with CRC diagnosed before 36 years of age were enrolled from a high-risk CRC clinic at the University of California, San Francisco (UCSF), and a population-based Kaiser Permanente (KP) Health Plan cancer registry. Probands provided cancer family histories and tumors for microsatellite instability (MSI) testing and MSH2/MLH1 protein immunostaining. Germline MSH2 and MLH1 mutational analysis was performed. RESULTS: Forty-three probands were enrolled from UCSF and 23 from KP. The UCSF and KP probands had similar median age of onset of CRC (30 vs. 31 years) and the percentage with any personal or family history of another HNPCC-related cancer (70% vs. 74%). However, 28 of 40 (70%) of the UCSF tumors were MSI-H compared with 6 of 18 (33%) of KP tumors (P = 0.01), and 13 germline MSH2 or MLH1 mutations were found in the UCSF group compared with 0 in the KP group (P = 0.0001). In a multivariate analysis, institution (P = 0.002) and the total number of colorectal cancers in the family (P = 0.0001) were independent predictors of MSH2 or MLH1 mutation. CONCLUSIONS: Family history of cancer is an important feature of HNPCC, even among individuals with early onset CRC. Caution must be undertaken when extrapolating data regarding HNPCC from high-risk clinic populations to the general population.