Cost-minimisation analysis of plasma exchange versus IVIg in the treatment of autoimmune neurological conditions.

BACKGROUND: Plasma exchange (PLEX) is an effective treatment for antibody-mediated neurological disorders and has been shown to be equally efficacious to intravenous immunoglobulin (IVIg) with comparable adverse event profiles. IVIg has traditionally been the preferred treatment option due to its ease of use. However, advancing technology has allowed PLEX to be performed with a centrifugal system via peripheral access as opposed to central access via a membrane filter. METHODS: We prospectively collected data from a cohort of patients who underwent PLEX at the Wessex Neurological Centre, UK, to perform a cost-minimisation analysis comparing PLEX to IVIg, the standard of care, between May 2019 and May 2020. Data obtained included indication, admission type (inpatient, daycase or intensive care), access (peripheral or central), number of PLEX cycles, exchange volume, patient weight, complications and clinical outcomes. The cost of PLEX delivered in an outpatient setting for an average 80kg person was calculated and compared to the equivalent cost of delivering IVIg by means of a cost-minimization model. RESULTS: The provision of PLEX was roughly half as costly when compared to what it would have been for IVIg (£886 per exchange vs £1778 per infusion or £4432 per cycle of 5 exchanges vs £8890 per cycle of 5 infusions). Our cohort included a total of 44 patients who received a total of 357 PLEX exchanges during the 12-month period (the majority of which were in a daycase setting). We calculated an annual cost saving for PLEX over IVIg of £318,589. The robustness of this result was confirmed by a one-way deterministic sensitivity analysis, showing the cost-effectiveness of PLEX. CONCLUSION: Our findings demonstrate that PLEX is more cost-effective than IVIg in this setting. Our study supports the economic case for development of plasma exchange centres in regional neurology units, a case made all the more relevant in the context of constrained supplies of IVIg.

Saving the face of soil aggregates.

Hierarchy levels and building units of micro- and macroaggregates and related separation methods. The hierarchy levels (left arrow) are inversely related to the energy necessary for the disruption (right arrow).

Variations in soil erodibility (K-factor) for the Chernozems depending on the method of texture determination.

Soil erodibility (K-factor) is an important parameter in erosion modeling, is one of five factors of the Revised Universal Soil Loss Equation (RUSLE), and generally represents the soil's response to rainfall and run-off erosivity. The erodibility could be determined based on direct measurements of soil properties and mathematical calculations. In this study, the K-factor was calculated based on a formula from RUSLE, proposed by Renard et al. (1997). All input parameters: soil organic carbon (SOC), soil structure, and permeability classes were measured by one method, but particle size distribution - in two ways by sedimentation and laser diffraction methods to assess the impact the K-factor variability and the values of soil erosion rates. The 107 soil samples of Chernozems from Kursk Oblast (Russia) were studied. The texture for the most of samples was classified as silty loam in both analyses. However, the laser diffraction underestimates the clay content by an average of 13.2 % compared to the pipette method. The average K-factor estimated based on laser diffraction data was 0.050, and 0.034 t ha h ha-1 MJ-1 mm-1 - sedimentation method. Thus, depending on the method of soil texture analysis, the RUSLE calculated soil loss could underestimated/overstated by 32 % (or 4 t ha-1 yr-1 on average in the study site). Therefore, we propose a regression equation-based conversion method of laser diffraction data to sedimentation method data for Chernozems.•The Laska-TM laser analyzer measured on ∼ 13 % less clay fraction (more on ∼ 8 % silt and ∼ 5 % fine sand) compared with sedimentation method data.•For erosional researchers/modelers it is suggested to state the method of soil texture analysis (based on sedimentation law or laser diffraction) was used for RUSLE K-factor calculations.•To convert K-factor values (for Chernozems) calculated and based on data of the sedimentation method to laser sedimentation - it suggested utilize the coefficient 1.47 (0.68 - vice versa).

Shifting Mountain Tree Line Increases Soil Organic Carbon Stability Regardless of Land Use.

Climate and land use changes are causing trees line to shift up into mountain meadows. The effect of this vegetation change on the partitioning of soil carbon (C) between the labile particulate organic matter (POM-C) and stable mineral-associated organic matter (MAOM-C) pools is poorly understood. Therefore, we assessed these C pools in a 10 cm topsoil layer along forest-meadow ecotones with different land uses (reserve and pasture) in the Northwest Caucasus of Russia using the size fractionation technique (POM 0.053-2.00 mm, MAOM < 0.053 mm). Potential drivers included the amount of C input from aboveground grass biomass (AGB) and forest litter (litter quantity) and their C/N ratios, aromatic compound content (litter quality), and soil texture. For both land uses, the POM-C pool showed no clear patterns of change along forest-meadow ecotones, while the MAOM-C pool increased steadily from meadow to forest. Regardless of land use, the POM-C/MAOM-C ratio decreased threefold from meadow to forest in line with decreasing grass AGB (R2 = 0.75 and 0.29 for reserve and pasture) and increasing clay content (R2 = 0.63 and 0.36 for reserve and pasture). In pastures, an additional negative relationship was found with respect to plant litter aromaticity (R2 = 0.48). Therefore, shifting the mountain tree line in temperate climates could have a positive effect on conserving soil C stocks by increasing the proportion of stable C pools.

Localization of C Cycle Enzymes in Arable and Forest Phaeozems within Levels of Soil Microstructure.

Soil microbial and enzyme activities are closely related to the spatial variability of soil environmental conditions at the microscale (µm-mm). The origin and localization of the enzymes are somewhat neglected when the measured activity is used to evaluate specific soil functions. The activity of four hydrolytic enzymes (ß-glucosidase, Cellobiohydrolase, Chitinase, Xylanase) and microbial diversity based on community-level physiological profiling were determined in samples of arable and native Phaeozems with increasing physical impact to soil solids. The level of impact on the soil solids had a significant effect on enzyme activity and depended on both the enzyme type and soil land use. The highest proportion of the activity of Xylanase and Cellobiohydrolase of arable Phaeozem was determined at the dispersion energy in the range of 450-650 J·mL-1 and was associated with the primary soil particles' hierarchy level. The highest proportions of ß-glucosidase and Chitinase activities were determined for forest Phaeozem after applying energies lower than 150 J·mL-1 and characterizing the level of soil microaggregates. The increased activity of Xylanase and Cellobiohydrolase in primary soil particles of arable soil compared to those in forest soil might be a reflection of the substrates being unavailable to decomposition, leading to enzyme accumulation on the solid surface. For the Phaeozems, the lower the level of soil microstructure organization, the greater the differences observed between soils of different land use type, i.e., microbial communities, associated with lower microstructure levels, were more specific to land use type.

Comparison of IVIg and TPE efficacy in the treatment of neurological disorders: a systematic literature review.

Background: Intravenous immunoglobulin (IVIg) and therapeutic plasma exchange (TPE) are among the main immunotherapies for neurological disorders. Their benefit is greatest in immune-mediated conditions, but their distinct efficacy cannot be simply explained. Objectives: This review aimed to systematically identify studies comparing the efficacy of TPE and IVIg treatments for selected autoimmune neurological disorders and identify optimal therapies for each condition. Data Sources and Methods: PubMed, MEDLINE and Embase databases were searched for original publications from 1990 to 2021. Additional publications were identified via expert recommendations. Conference abstracts older than 2017, review articles and articles without information on TPE and IVIg comparison in title and abstract were excluded. Risks of bias were descriptively addressed, without a meta-analysis. Results: Forty-four studies were included on Guillain-Barré syndrome (20 studies - 12 adult, 5 paediatric, 3 all ages), myasthenia gravis (11 studies -8 adult, 3 paediatric), chronic immune-mediated polyradiculoneuropathy (3 studies -1 adult, 2 paediatric), encephalitis (1 study in adults), neuromyelitis optica spectrum disorders (5 studies -2 adult, 3 all ages) and other conditions (4 studies - all ages). TPE and IVIg were mostly similarly efficacious, measured by clinical outcomes and disease severity scores. Some studies recommended IVIg as easy to administer. TPE procedures, however, have been simplified and the safety has been improved. TPE is currently recommended for management of neuromyelitis optica spectrum disorder relapses and some myasthenia gravis subtypes, in which rapid removal of autoantibodies is crucial. Conclusion: Despite some limitations (e.g. the low evidence levels), this review provides an extensive 30-year-long overview of treatments for various conditions. Both IVIg and TPE are usually comparably efficacious options for autoimmune neurological disorders, with few exceptions. Treatment choices should be patient-tailored and based on available clinical resources. Better designed studies are needed to provide higher-level quality of evidence regarding clinical efficacy of TPE and IVIg treatments.

Ultrasound-induced cell permeabilisation and hyperthermia: strategies for local delivery of compounds with intracellular mode of action.

There is an increasing clinical need for novel, externally triggered, local drug delivery methods since many drugs are characterised by high systemic toxicity and/or suffer from limited bioavailability. Thermosensitive liposomes (TSLs) demonstrate great potential for local delivery and release of the payload. They are particularly effective in combination with ultrasound (US) under magnetic resonance (MR) guidance that is known to induce hyperthermia locally in a precisely controlled manner. Bioeffects of hyperthermia include increased blood flow, blood volume and enhanced vascular permeability thus potentiating anti-tumoural efficacy of TSLs. However, bioeffects of ultrasound are not limited to hyperthermia only, and under certain parameters may include locally enhanced extravasation and permeabilisation of cell membrane for compounds. This opens up opportunities for delivery of cell-impermeable and weakly permeable drugs that can be employed together with thermosensitive liposomes. In the latter case US-mediated cavitation and/or radiation forces local permeabilisation of the cells and US-induced hyperthermia releases the drug. This review focuses on bioeffects of US such as hyperthermia, enhanced extravasation and cell permeabilisation utilised for local drug delivery.

The Role of Plasma Exchange in the Treatment of Refractory Autoimmune Neurological Diseases: a Narrative Review.

Autoimmune neurological disorders are commonly treated with immunosuppressive therapy. In patients with refractory conditions, standard immunosuppression is often insufficient for complete recovery or to prevent relapses. These patients rely on other treatments to manage their disease. While treatment of refractory cases differs between diseases, intravenous immunoglobulin, plasma exchange (PLEX), and immune-modulating treatments are commonly used. In this review, we focus on five autoimmune neurological disorders that were the themes of the 2018 Midlands Neurological Society meeting on PLEX in refractory neurology: Autoimmune Encephalitis (AE), Multiple Sclerosis (MS), Neuromyelitis Optica Spectrum disorders (NMOSD), Chronic Inflammatory Demyelinating Polyradiculoneuropathy (CIDP) and Myasthenia Gravis (MG). The diagnosis of inflammatory neuropathies is often challenging, and while PLEX can be very effective in refractory autoimmune diseases, its ineffectiveness can be confounded by misdiagnosis. One example is POEMS syndrome (characterized by Polyneuropathy Organomegaly, Endocrinopathy, Myeloma protein, Skin changes), which is often wrongly diagnosed as CIDP; and while CIDP responds well to PLEX, POEMS does not. Accurate diagnosis is therefore essential. Success rates can also differ within 'one' disease: e.g. response rates to PLEX are considerably higher in refractory relapsing remitting MS compared to primary or secondary progressive MS. When sufficient efforts are made to correctly pinpoint the diagnosis along with the type and subtype of refractory autoimmune disease, PLEX and other immunotherapies can play a valuable role in the patient management.

Spatial Changes in Microbial Communities along Different Functional Zones of a Free-Water Surface Wetland.

Constructed wetlands (CWs) are complicated ecosystems that include vegetation, sediments, and the associated microbiome mediating numerous processes in wastewater treatment. CWs have various functional zones where contrasting biochemical processes occur. Since these zones are characterized by different particle-size composition, physicochemical conditions, and vegetation, one can expect the presence of distinct microbiomes across different CW zones. Here, we investigated spatial changes in microbiomes along different functional zones of a free-water surface wetland located in Moscow, Russia. The microbiome structure was analyzed using Illumina MiSeq amplicon sequencing. We also determined particle diameter and surface area of sediments, as well as chemical composition of organic pollutants in different CW zones. Specific organic particle aggregates similar to activated sludge flocs were identified in the sediments. The highest accumulation of hydrocarbons was found in the zones with predominant sedimentation of fine fractions. Phytofilters had the highest rate of organic pollutants decomposition and predominance of Smithella, Ignavibacterium, and Methanothrix. The sedimentation tank had lower microbial diversity, and higher relative abundances of Parcubacteria, Proteiniclasticum, and Macellibacteroides, as well as higher predicted abundances of genes related to methanogenesis and methanotrophy. Thus, spatial changes in microbiomes of constructed wetlands can be associated with different types of wastewater treatment processes.

Characterizing vascular parameters in hypoxic regions: a combined magnetic resonance and optical imaging study of a human prostate cancer model.

The integration of imaging technologies with the capabilities of genetic engineering has created novel opportunities for understanding and imaging cancer. Here, we have combined vascular magnetic resonance imaging (MRI) and optical imaging to understand the relationship between hypoxia and vascularization in a human prostate cancer model engineered to express enhanced green fluorescent protein (EGFP) under hypoxia. Characterization and validation of EGFP expression under hypoxic conditions was done in culture and in solid tumors in vivo. MRI measurements showed that vascular volume was significantly lower in fluorescing regions. These regions also frequently exhibited high permeability. These data were further supported by the detection of low vessel density in EGFP-positive regions, as determined by the distribution of intravascularly administered, fluorescence-labeled Lycopersicon esculentum lectin in frozen tumor sections. These observations are consistent with the possibility that regions of low vascular volumes are hypoxic, which induces increased expression of functionally active vascular endothelial growth factor, a potent vascular permeability factor.

Detection of early antiangiogenic effects in human colon adenocarcinoma xenografts: in vivo changes of tumor blood volume in response to experimental VEGFR tyrosine kinase inhibitor.

Antiangiogenesis is emerging as efficient strategy for targeting and potentially eliminating neoplastic tumor vessels. The main goal of this study was to establish whether absolute tumor blood volume (V(b)) change could be used as an early predictor of antiangiogenesis in ectopic and orthotopic colon carcinomas. To assess therapy-induced changes of V(b), we did comparative analysis of signal intensities in tumors and muscle using steady-state magnetic resonance imaging (MRI) assisted with an intravascular paramagnetic contrast agent [gadolinium-labeled protected graft copolymer (PGC-Gd)]. Athymic mice with implanted human MV522 tumors were treated with vascular endothelial growth factor type 2 receptor tyrosine kinase inhibitor (VEGFR2-TKI) that has been shown to inhibit VEGFR2 phosphorylation and tumor growth in vivo. Animals were imaged either after a single day or after a 1-week course of treatments. The measured V(b) in ectopic tumors was 2.5 +/- 1.5% of total tissue volume 1 week after the implantation (n = 8). Two doses of VEGFR2-TKI (25 mg/kg, p.o., b.i.d.) resulted in a decrease of V(b) to 1.3 +/- 0.3%. In orthotopic tumors, the measured V(b) was initially higher (11.9 +/- 2.0%); however, VEGFR2-TKI treatment also resulted in a statistically significant decrease of V(b). The absolute V(b) was not affected in the muscle as a result of treatments. MRI measurements were corroborated by using isotope and correlative histology experiments. Our results show that steady-state MRI is highly sensitive to early antiangiogenic effects caused by small molecule drugs.

Real-time assessment of ultrasound-mediated drug delivery using fibered confocal fluorescence microscopy.

PURPOSE: Transport across the plasma membrane is a critical step of drug delivery for weakly permeable compounds with intracellular mode of action. The purpose of this study is to demonstrate real-time monitoring of ultrasound (US)-mediated cell-impermeable model drug uptake with fibered confocal fluorescence microscopy (FCFM). PROCEDURES: An in vitro setup was designed to combine a mono-element US transducer, a cell chamber with a monolayer of tumor cells together with SonoVue microbubbles, and a FCFM system. The cell-impermeable intercalating dye, SYTOX Green, was used to monitor US-mediated uptake. RESULTS: The majority of the cell population showed fluorescence signal enhancement 10 s after US onset. The mean rate constant k of signal enhancement was calculated to be 0.23 ± 0.04 min(-1). CONCLUSIONS: Feasibility of real-time monitoring of US-mediated intracellular delivery by FCFM has been demonstrated. The method allowed quantitative assessment of model drug uptake, holding great promise for further local drug delivery studies.

Observations on the viability of C6-glioma cells after sonoporation with low-intensity ultrasound and microbubbles.

Ultrasound (US) and microbubbles can be used to facilitate cellular uptake of drugs through a cavitationinduced enhancement of cell membrane permeability. The mechanism is, however, still incompletely understood. A direct contact between microbubbles and cell membrane is thought to be essential to create membrane perturbations lasting from seconds to minutes after US exposure of the cells. A recent study showed that the effect may even last up to 8 h after cavitation (with residual permeability up to 24 h after cavitation). In view of possible membrane damage, the purpose of this study was to further investigate the evolution of cell viability in the range of the 24-h temporal window. Furthermore, a description of the functional changes in tumor cells after US exposure was initiated to obtain a better understanding of the mechanism of membrane perturbation after sonication with microbubbles. Our results suggest that US does not reduce cell viability up to 24 h post-exposure. However, a perturbation of the entire cell population exposed to US was observed in terms of enzymatic activity and characteristics of the mitochondrial membrane. Furthermore, we demonstrated that US cavitation induces a transient loss of cell membrane asymmetry, resulting in phosphatidylserine exposure in the outer leaflet of the cell membrane.

Quantitative evaluation of ultrasound-mediated cellular uptake of a fluorescent model drug.

PURPOSE: This study aims to quantitatively analyze cellular uptake following local ultrasound (US)-mediated cell permeabilization. PROCEDURES: A 2 µM cell-impermeable dye Sytox Green was co-injected with 3 × 10(7) microbubbles in the presence of C6 rat glioblastoma cell monolayer in total volume of 10 ml. A 5.8-mm diameter mono-element US transducer was positioned at a distance of 8 mm to the Opticell® membrane. Acoustical pressure of pulsed US was varied from 0.62 MPa peak-to-peak (p-p) to 1.25 MPa p-p. Large field of view (FOV = 15 × 15 mm) 22 × 22 mosaic acquisitions were done under epifluorescence Leica DMR microscope and analyzed in Metamorph software to evaluate cell density as well as model drug uptake percentage. RESULTS: The size of acoustical field of the transducer closely matches the spatial pattern of the model drug internalized into the cells by US. Maximum of uptake percentage (42 ± 15 %) was found at 0.88 MPa p-p. CONCLUSIONS: Spatial aspect of US-mediated model drug uptake has been quantitatively evaluated on adherent cells using robust 2D-mapping approach.

In vivo temperature controlled ultrasound-mediated intracellular delivery of cell-impermeable compounds.

Many chemotherapeutic drugs are characterized by high systemic toxicity and/or suffer from limited bioavailability. Thermosensitive liposomes (TSLs) encapsulating drugs in their aqueous lumen are promising activatable nanocarriers for ultrasound (US)-mediated drug delivery in response to mild hyperthermia. On the other hand, US is known to locally break biological barriers and as a consequence enable internalization of molecules. In this work, a two-step protocol for intracellular delivery of cell-impermeable molecules comprising of US-induced permeabilization followed by temperature-controlled release of the model drug from thermosensitive liposomes has been developed. TSLs containing TO-PRO-3, a cell-impermeable molecule that displays a significant increase in fluorescence upon binding to nucleic acids thus serving as a 'sensor' for internalization have been prepared and characterized in detail. US-mediated permeabilization followed by temperature-controlled release was applied to tumor bearing mice following i.v. injection of TSLs and microbubbles. The efficacy of this approach was evaluated by in vivo fluorescence imaging followed by histological analysis. A 2.4-fold increase of fluorescence signal was observed and intracellular delivery of TO-PRO-3 was confirmed by a characteristic nuclear staining. These results demonstrate the feasibility of novel drug delivery system to tumors comprising of local cell permeabilization by US followed by in situ release of the payload from thermosensitive liposomes. Possible applications include local and controlled intracellular delivery of molecules with otherwise limited bioavailability.

Evaluation of the temporal window for drug delivery following ultrasound-mediated membrane permeability enhancement.

PURPOSE: Ultrasound-induced cavitation facilitates cellular uptake of drugs via increased membrane permeability. Here, the purpose was to evaluate the duration of enhanced membrane permeability following ultrasound treatment in cell culture. PROCEDURES: Optical chromophores with fluorescence intensity increasing 100-1,000-fold upon intercalation with nucleic acids served as smart agents for reporting cellular uptake. Opticell chambers with a monolayer of C6 cells were subjected to ultrasound in the presence of microbubbles followed by varying delays between 0 and 24 h before addition of Sytox Green optical contrast agent. Micro- and macroscopic fluorescence were used for qualitative and quantitative analysis. RESULTS: Up to 25% of viable cells showed uptake of contrast agent with a half time of 8 h, with cellular uptake persisting even at 24 h. Only cells exposed to ultrasound showed the effect. CONCLUSION: The temporal window of increased membrane permeability is much longer in these studies than previously suggested. This may have important repercussions for in vivo studies in which membrane permeability may be temporally separated from drug delivery.

A fluorescent chromophore TOTO-3 as a 'smart probe' for the assessment of ultrasound-mediated local drug delivery in vivo.

Many potent anti-cancer drugs have an intracellular mode of action, but are limited in crossing the cell membrane, resulting in a reduced clinical efficacy. Ultrasound (US) is known to facilitate the penetration of drugs into tumors cells. However (molecular) imaging techniques that monitor in vivo the underlying processes of US-triggered drug delivery are lacking. The objective of this study was to demonstrate the feasibility of using a fluorescent nuclear acid stain (TOTO-3) as a model drug to monitor in real-time US-mediated delivery by in vivo fluorescence imaging. Following co-injection of TOTO-3 and microbubbles US was applied to the tumor. The time course of the drug delivery process was monitored by fluorescence imaging. Immunohistological analysis and in vitro experiments were performed to investigate the results in more detail. A significant signal intensity enhancement of the US-treated tumor was observed that indicates intracellular delivery of the dye. In the control tumor TOTO-3 signal was strongly associated with macrophages, which was not the case for the sonicated tumor. The capability of macrophages to uptake TOTO-3 was confirmed in vitro. This study demonstrates that an optical contrast agent with similar characteristics to an anti-cancer drug may be used for continuous in vivo monitoring of the drug delivery process.

Synthesis and testing of a binary catalytic system for imaging of signal amplification in vivo.

We report a binary targeted enzymatic system that is composed of two covalent monoclonal antibody conjugates for specific labeling of cellular targets in vivo. The system utilizes low-molecular weight peroxidase-reducing substrates synthesized by linking 5-hydroxytryptamine (serotonin) with DTPA (5HT-DTPA) for magnetic resonance and radionuclide imaging or with Cy5.5 for near-infrared optical imaging. Initially, the conjugation reaction conditions were optimized to achieve a low level of antiepidermal growth factor receptor (EGFR) antibody (EMD 72000) modification with the N-hydroxysuccinimide ester of 4-hydrazinonicotinate acetone hydrazone (SANH), yielding mAb-HNH conjugate. The resultant modified antibodies were incubated with the periodate-oxidized peroxidase (HRP) or 4-formylbenzoyl-conjugated glucose oxidase (GO), followed by the purification of the resultant mAb-enzyme conjugates by size-exclusion HPLC. The conjugates were further characterized by electrophoresis and were tested by cross-titration on A431 EGFR+ squamous carcinoma or SW620 adenocarcinoma cells (negative control). The conjugates at the optimized concentration ratios were further tested using near-infrared fluorescence microscopy in the presence of Cy5.5 monocarboxy-5-hydroxytryptamide. Further in vitro experiments demonstrated that (1) antibody binding was specific and could be inhibited by free antibody; (2) both antibody conjugates exhibited high enzymatic activity after the binding to the cells; (3) 111In-labeled 5-HT-DTPA was avidly binding to EGFR-positive cells only if both HRP- and GO-conjugates were bound to the cells. The conjugates were tested in vivo using a SPECT imaging experiment, which demonstrated the accumulation of 111In-labeled 5-HT-DTPA substrate at the site containing both conjugates.