A National Spinal Muscular Atrophy Registry for Real-World Evidence.

BACKGROUND: Spinal muscular atrophy (SMA) is a devastating rare disease that affects individuals regardless of ethnicity, gender, and age. The first-approved disease-modifying therapy for SMA, nusinursen, was approved by Health Canada, as well as by American and European regulatory agencies following positive clinical trial outcomes. The trials were conducted in a narrow pediatric population defined by age, severity, and genotype. Broad approval of therapy necessitates close follow-up of potential rare adverse events and effectiveness in the larger real-world population. METHODS: The Canadian Neuromuscular Disease Registry (CNDR) undertook an iterative multi-stakeholder process to expand the existing SMA dataset to capture items relevant to patient outcomes in a post-marketing environment. The CNDR SMA expanded registry is a longitudinal, prospective, observational study of patients with SMA in Canada designed to evaluate the safety and effectiveness of novel therapies and provide practical information unattainable in trials. RESULTS: The consensus expanded dataset includes items that address therapy effectiveness and safety and is collected in a multicenter, prospective, observational study, including SMA patients regardless of therapeutic status. The expanded dataset is aligned with global datasets to facilitate collaboration. Additionally, consensus dataset development aimed to standardize appropriate outcome measures across the network and broader Canadian community. Prospective outcome studies, data use, and analyses are independent of the funding partner. CONCLUSION: Prospective outcome data collected will provide results on safety and effectiveness in a post-therapy approval era. These data are essential to inform improvements in care and access to therapy for all SMA patients.

Shortened therapy of eight weeks with paritaprevir/ritonavir/ombitasvir and dasabuvir is highly effective in people with recent HCV genotype 1 infection.

Paritaprevir/ritonavir/ombitasvir and dasabuvir with or without ribavirin for 12 weeks are approved for treatment of chronic HCV genotype 1 infection. This study assessed the efficacy of shortened duration paritaprevir/ritonavir/ombitasvir and dasabuvir with or without ribavirin for 8 weeks among people with recent HCV infection. In this open-label single-arm trial conducted in Australia, England and New Zealand, adults with recent HCV (duration of infection <12 months) received paritaprevir/ritonavir/ombitasvir and dasabuvir (with weight-based ribavirin for genotypes 1a and 1, no subtype) for 8 weeks. The primary endpoint was sustained virological response at 12 weeks post-treatment (SVR12) in the intention-to-treat (ITT) population. Thirty people (median age 38 years, male 93%) commenced treatment (with ribavirin, 97%), of whom 77% (n = 23) were HIV-positive, 93% (n = 28) had genotype 1a infection and 53% (n = 16) had ever injected drugs. Median maximum ALT in the preceding 12 months was 433 IU/L (IQR 321, 1012). Acute clinical hepatitis with ALT > 10 x ULN was documented in 83% (n = 25); one participant (3%) had jaundice. At baseline, median estimated duration of infection was 30 weeks (range 11, 51), and median HCV RNA was 5.7 log10 IU/mL (range 2.7, 7.3). SVR12 was achieved in 97% (29/30; early discontinuation at week 2, n = 1; per protocol 100%, 29/29). No relapse or reinfection was observed. In conclusion, paritaprevir/ritonavir/ombitasvir and dasabuvir (with ribavirin) for eight weeks were highly effective among HIV-positive and HIV-negative individuals with recent HCV infection. These data support the use of this shortened duration direct-acting antiviral regimen in this population.

Week 96 results of the randomized, multicentre Maraviroc Switch (MARCH) study.

OBJECTIVES: The Maraviroc Switch (MARCH) study week 48 data demonstrated that maraviroc, a chemokine receptor-5 (CCR5) inhibitor, was a safe and effective switch for the ritonavir-boosted protease inhibitor (PI/r) component of a two nucleos(t)ide reverse transcriptase inhibitor [N(t)RTI] plus PI/r-based antiretroviral regimen in patients with R5-tropic virus. Here we report the durability of this finding. METHODS: MARCH, an international, multicentre, randomized, 96-week open-label switch study, enrolled HIV-1-infected adults with R5-tropic virus who were stable (> 24 weeks) and virologically suppressed [plasma viral load (pVL) < 50 HIV-1 RNA copies/mL]. Participants were randomized to continue their current PI/r-based regimen (PI/r) or to switch to MVC plus two N(t)RTIs (MVC) (1:2 randomization). The primary endpoint was the difference in the proportion with pVL < 200 copies/mL at 96 weeks. The switch arm was defined as noninferior if the lower limit of the 95% confidence interval (CI) for the difference was < -12% in the intention-to-treat (ITT) population. Safety endpoints (the difference in the mean change from baseline or a comparison of proportions) were analysed as key secondary endpoints. RESULTS: Eighty-two (PI/r) and 156 (MVC) participants were randomized and included in the ITT analysis; 71 (87%) and 130 (83%) were in follow-up and on therapy at week 96. At week 96, 89.0% and 90.4% in the PI/r and MVC arms, respectively, had pVL < 50 copies/mL (95% CI -6.6, 10.2). Moreover, in those switching away from PI/r, there were significant reductions in mean total cholesterol (differences 0.31 mmol/L; P = 0.02) and triglycerides (difference 0.44 mmol/L; P < 0.001). Changes in CD4 T-cell count, renal function, and serious and nonserious adverse events were similar in the two arms. CONCLUSIONS: MVC as a switch for a PI/r is safe and effective at maintaining virological suppression while having significant lipid benefits over 96 weeks.

Organ donor screening using parallel nucleic acid testing allows assessment of transmission risk and assay results in real time.

Expansion of the donor pool may lead to utilization of donors with risk factors for viral infections. Donor laboratory screening relies on serological and nucleic acid testing (NAT). The increased sensitivity of NAT in low prevalence populations may result in false-positive results (FPR) and may cause unnecessary discard of organs.We developed a screening algorithm to deal, in real time, with potential FPR. Three NAT assays: COBAS AmpliScreen assay (CAS), AmpliPrep Total Nucleic Acid Isolation/CAS, and AmpliPrep/TaqMan assays, were validated and used in parallel for prospective screening of increased-risk donors (IRD), and the probability of FPR was calculated. The lower limit of detection of this algorithm was 9.79, 21.02, and 4.31 IU/mL for human immunodeficiency virus-1, hepatitis C virus, and hepatitis B virus, respectively, with an average turn-around-time of 7.67 h from sample receipt to result reporting. The probability that a donor is potentially infectious with two NAT concordant results was >90%. NAT screening of 35 IRD within 18 months resulted in transplantation of 102 additional organs that without screening would either not be used or used with restrictions in Australia. Using a parallel testing algorithm, real-time confirmation of seropositive donors allows use of organs from IRD and safer expansion of the donor pool.

Microsporidia and Acanthamoeba: the role of emerging corneal pathogens.

Parasitic organisms are increasingly recognized as human corneal pathogens. A notable increase in both well-defined Acanthamoeba keratitis and a more dramatic increase in reported cases of Microsporidia keratitis have suggested significant outbreaks of parasitic keratitis around the world. Historical and contemporary baselines as well as a familiar associated clinical presentation reinforce the significant outbreak of Acanthamoeba keratitis in the United States. The remarkable rise in cases of Microsporidia keratitis, however, lacks these established baselines and, further, describes a disease that is inconsistent with previous definitions of disease. While a well-defined, abrupt increase strongly suggests temporally related risk factors, most likely environmental, involved in the Acanthamoeba outbreak, the rise in Microsporidia keratitis suggests that increased awareness and improved diagnostic acumen are a significant factor in case ascertainment. Regardless, recent evidence indicates that both parasitic diseases are likely underreported in various forms of infectious keratitis, which may have unrecognized but significant implications in the pathogenesis of both primary protozoal and polymicrobial keratitis. Further understanding of the incidence and interaction of these organisms with current therapeutic regimens and more commonly recognized pathogens should significantly improve diagnosis and alter clinical outcomes.

Estimating the total exposure to air pollutants for different population age groups in Hong Kong.

Given that Hong Kong is one of the most densely populated cities in the world, the exposure of the Hong Kong people is one of the interesting research areas. In this study, an indirect approach was used to estimate the exposure to nitrogen dioxide (NO2), respiratory dust (PM10) and carbon monoxide (CO) pollutants experienced by different age groups of people in Hong Kong. The average concentrations of the 20 major microenvironments obtained from our measurement survey data, together with the people activity pattern data obtained from 7-day recall questionnaires, were used to predict frequency distributions to exposure assessment. Our results showed that Hong Kong people spent more than 86% of their time indoors. Homes were shown to be the one of the major exposure sites to NO2, CO and PM10 for all age groups. Our results also indicate that the 24-h NO2 exposure for individuals, irrespective of age, spending more than 2 h in commuting daily, was observed to be exceeding the 24-h NO2 exposure standards. This study was one of the pioneering studies with valuable contribution for modeling the estimates of exposures to NO2, PM10 and CO of different age groups in Hong Kong.

Corneal first surface optical aberrations and visual performance.

PURPOSE: Wavefront analysis has demonstrated that refractive surgery-induced corneal first surface aberrations are large, are dominated by symmetric aberrations (spherical-like aberrations), and are correlated to measures of visual performance. It is not clear whether the correlation between corneal first surface aberrations and visual performance can be generalized to other corneal conditions where large asymmetric aberrations (coma-like aberrations) may dominate the aberration structure. The purpose of the research reported here was to determine the general utility of corneal first surface wavefront analysis in predicting visual performance. METHODS: Patients were 13 normals and 78 patients with a variety of corneal conditions including surgically removed pterygia, penetrating keratoplasty, keratoconus, radial keratotomy, laser in situ keratomileusis, and others. Videokeratographs were taken for all patients and used to calculate corneal first surface wavefront variance for 3 and 7 mm pupils. Similarly, visual performance was quantified by measurements of contrast sensitivity and high and low contrast acuities through both 3 and 7 mm pupils. RESULTS: Statistically significant correlations existed between all three measures of visual performance and the corneal wavefront variance. All relationships were stronger for the 7 mm diameter-pupil condition than the 3 mm pupil. CONCLUSION: Regardless of the cause, corneas with increased wavefront variance showed a quantifiable decrease in visual performance that was pupil size dependent.

Immunoperoxidase technique for detecting spirochetes in tissue sections: comparison with other methods.

BACKGROUND: With the increasing incidence of human immunodeficiency virus (HIV) infection and immunosuppressive therapy, the incidence of syphilis has been increasing. Given the fact that the above conditions may mask or obscure the usual clinical signs and symptoms of syphilis, a means of enhanced detection is essential. AIMS METHODS: The purpose of this study was to determine whether an immunoperoxidase method using an antibody against treponemes would increase the sensitivity and specificity of diagnosis in biopsies of patients with secondary syphilis. This was compared to serology and silver stain in cases of known syphilis. RESULTS: Immunoperoxidase for treponemes was at least as sensitive (9/10) as pathology (9/10), and more sensitive than conventional silver stain (6/10) or serology (7/10). CONCLUSIONS: In those equivocal cases of secondary syphilis, where confirmation is essential, immunoperoxidase for treponemes may be a useful adjunct.

Rapid, high fidelity analysis of simple sequence repeats on an electronically active DNA microchip.

We describe a method for the discrimination of short tandem repeat (STR) alleles based on active microarray hybridization. An essential factor in this method is electronic hybridization of the target DNA, at high stringency, in <5 min. High stringency is critical to avoid slippage of hybrids along repeat tracts at allele-specific test sites in the array. These conditions are attainable only with hybridization kinetics realized by electronic concentration of DNA. A sandwich hybrid is assembled, in which proper base stacking of juxtaposed terminal nucleotides results in a thermodynamically favored complex. The increased stability of this complex relative to non-stacked termini and/or base pair mismatches is used to determine the identification of STR alleles. This method is capable of simultaneous and precise identification of alleles containing different numbers of repeats, as well as mutations within these repeats. Given the throughput capabilities of microarrays our system has the potential to enhance the use of microsatellites in forensic criminology, diagnostics and genetic mapping.

Active microeletronic chip devices which utilize controlled electrophoretic fields for multiplex DNA hybridization and other genomic applications.

Microelectronic DNA chip devices that contain planar arrays of microelectrodes have been developed for multiplex DNA hybridization and a variety of genomic research and DNA diagnostic applications. These devices are able to produce almost any desired electric field configuration on their surface. This ability to produce well-defined electric fields allows charged molecules (DNA, RNA, proteins, enzymes, antibodies, nanobeads, and even micron scale semiconductor devices) to be electrophoretically transported to or from any microlocation on the planar surface of the device. Of key importance to the device function is the permeation layer which overcoats the microelectrodes. The permeation layer is generally a porous hydrogel material that allows water molecules and small ions (Na+, CI-, etc.) to freely contact the microelectrode surface, but impedes the transport of the larger analytes (oligonucleotides, DNA, RNA, proteins, etc.). The permeation layer prevents the destruction of DNA at the active microelectrode surface, ameliorates the adverse effects of electrolysis products on the sensitive hybridization reactions, and serves as a porous support structure for attaching DNA probes and other molecules to the array. In order to maintain rapid transport of DNA molecules, facilitate hybridization, and work within constrained current and voltage ranges, low conductance buffers and various electronic pulsing scenarios have also been developed. These active microelectronic array devices allow electrophoretic fields to be used to carry out accelerated DNA hybridization reactions and to improve selectivity for single nucleotide polymorphism (SNP), short tandem repeat (STR), and point mutation analysis.

Rapid determination of single base mismatch mutations in DNA hybrids by direct electric field control.

We have demonstrated that controlled electric fields can be used to regulate transport, concentration, hybridization, and denaturation of single- and double-stranded oligonucleotides. Discrimination among oligonucleotide hybrids with widely varying binding strengths may be attained by simple adjustment of the electric field strength. When this approach is used, electric field denaturation control allows single base pair mismatch discrimination to be carried out rapidly (<15 sec) and with high resolution. Electric field denaturation takes place at temperatures well below the melting point of the hybrids, and it may constitute a novel mechanism of DNA denaturation.

Electric field directed nucleic acid hybridization on microchips.

Selection and adjustment of proper physical parameters enables rapid DNA transport, site selective concentration, and accelerated hybridization reactions to be carried out on active microelectronic arrays. These physical parameters include DC current, voltage, solution conductivity and buffer species. Generally, at any given current and voltage level, the transport or mobility of DNA is inversely proportional to electrolyte or buffer conductivity. However, only a subset of buffer species produce both rapid transport, site specific concentration and accelerated hybridization. These buffers include zwitterionic and low conductivity species such as: d- and l-histidine; 1- and 3-methylhistidines; carnosine; imidazole; pyridine; and collidine. In contrast, buffers such as glycine, beta-alanine and gamma-amino-butyric acid (GABA) produce rapid transport and site selective concentration but do not facilitate hybridization. Our results suggest that the ability of these buffers (histidine, etc.) to facilitate hybridization appears linked to their ability to provide electric field concentration of DNA; to buffer acidic conditions present at the anode; and in this process acquire a net positive charge which then shields or diminishes repulsion between the DNA strands, thus promoting hybridization.

Probabilities and lifetime durations of short-stay hospital and nursing home use in the United States, 1985.

OBJECTIVES: The authors present a four-state increment-decrement life table model from which estimates of the risk and duration of nursing home and short-term hospital stays in the United States are derived. METHODS: Survival analysis was used to generate various transition probabilities while controlling for population heterogeneity. In addition, a newly developed algorithm was applied to construct the multistate life table specifically for health-care use. RESULTS: The results reveal that in 1985, a US civilian is expected to spend 72.35 years in the community, 59.5 days in short-stay hospitals, and 2.28 years in nursing homes throughout his or her lifetime. CONCLUSIONS: The single-year risk of nursing home and short-stay hospital use is shown to be an increasing function of age, especially for the older adults.

Therapy of nonnecrotizing anterior scleritis with subconjunctival corticosteroid injection.

OBJECTIVE: To determine the safety and efficacy of subconjunctival triamcinolone (Kenalog) in treating nonnecrotizing anterior scleritis. DESIGN: The authors conducted a retrospective review of all patients treated with depot subconjunctival corticosteroid injection for scleritis from January 1988 to May 1993. Response to therapy was determined by subjective improvement in pain and a decrease in clinical signs of ocular inflammation. All patients received subconjunctival injections of triamcinolone by the same technique, and the minimum observation period for complications was 6 weeks. RESULTS: Eighteen patients (90%) had relief of their symptoms with clinically observable improvement in inflammation, whereas two patients (10%) responded poorly. Nine patients (45%) required no further therapy. Average symptom-free interval was 18 weeks in patients with recurrent scleritis. No complications of scleral thinning, perforation, or glaucoma occurred in any patients. CONCLUSION: Subconjunctival triamcinolone injection is highly efficacious in treating nonnecrotizing anterior scleritis without unreasonable risk of thinning and/or perforation and should be considered as adjunctive therapy in localized disease.