Clinical predictors of donor antibody titre and correlation with recipient antibody response in a COVID-19 convalescent plasma clinical trial.

BACKGROUND: Convalescent plasma therapy for COVID-19 relies on transfer of anti-viral antibody from donors to recipients via plasma transfusion. The relationship between clinical characteristics and antibody response to COVID-19 is not well defined. We investigated predictors of convalescent antibody production and quantified recipient antibody response in a convalescent plasma therapy clinical trial. METHODS: Multivariable analysis of clinical and serological parameters in 103 confirmed COVID-19 convalescent plasma donors 28 days or more following symptom resolution was performed. Mixed-effects regression models with piecewise linear trends were used to characterize serial antibody responses in 10 convalescent plasma recipients with severe COVID-19. RESULTS: Donor antibody titres ranged from 0 to 1 : 3892 (anti-receptor binding domain (RBD)) and 0 to 1 : 3289 (anti-spike). Higher anti-RBD and anti-spike titres were associated with increased age, hospitalization for COVID-19, fever and absence of myalgia (all P < 0.05). Fatigue was significantly associated with anti-RBD (P = 0.03). In pairwise comparison amongst ABO blood types, AB donors had higher anti-RBD and anti-spike than O donors (P < 0.05). No toxicity was associated with plasma transfusion. Non-ECMO recipient anti-RBD antibody titre increased on average 31% per day during the first three days post-transfusion (P = 0.01) and anti-spike antibody titre by 40.3% (P = 0.02). CONCLUSION: Advanced age, fever, absence of myalgia, fatigue, blood type and hospitalization were associated with higher convalescent antibody titre to COVID-19. Despite variability in donor titre, 80% of convalescent plasma recipients showed significant increase in antibody levels post-transfusion. A more complete understanding of the dose-response effect of plasma transfusion amongst COVID-19-infected patients is needed.

Impact of patient decision aids on appropriate and timely access to hip or knee arthroplasty for osteoarthritis: a randomized controlled trial.

OBJECTIVE: To evaluate the effectiveness of patient decision aids (PtDA) compared to usual education on appropriate and timely access to total joint arthroplasty in patients with osteoarthritis. METHOD: A randomized controlled trial (RCT) with patients undergoing orthopedic screening. Control and intervention arms received usual education; intervention arm also received a PtDA and a surgeon preference report. Wait times (primary outcome) were described using stratified Kaplan-Meier survival curves with patients censored at the time of death or loss to follow-up, and multivariable Cox proportional hazards regression. Secondary outcomes were compared using stratified Cochran-Mantel-Haenszel chi-squared tests. RESULTS: 343 patients were randomized to intervention (n = 174) or control (n = 169). The typical patient was 66 years old, retired, living with someone, and 51% had high school education or less. The intervention was associated with a trend towards reduction in wait time (hazard ratio (HR) 1.25, 95% confidence interval (CI) 0.99-1.60, P = 0.0653). Median wait times were 3 weeks shorter in intervention than in control at the community site with no difference at the academic site. Good decision quality was reached by 56.1% intervention and 44.5% control (Relative risk (RR) 1.25; 95% CI 1.00-1.56, P = 0.050). Surgery rates were 73.2% intervention and 80.5% controls (RR 0.91: 95% CI 0.81-1.03) with 12 intervention (7.3%) and eight control participants (4.9%) returning to have surgery within 2 years (P = 0.791). CONCLUSION: Compared to controls, decision aid recipients had shorter wait times at one site, fewer surgeries, and were more likely to reach good decision quality, but overall effect was not statistically significant. TRIALS REGISTRATION: The full trial protocol is available at ClinicalTrials.Gov (NCT00911638).

Clinical impact of treatment timing for chronic hepatitis C infection: a decision model.

Recent advances in the treatment of hepatitis C virus (HCV) infection have led to the availability of both highly efficacious interferon-containing and interferon-sparing regimens. However, the use of such therapies faces restrictions due to high costs. For patients who are medically eligible to receive interferon, the choice between the two will likely be impacted by preferences surrounding interferon, severity of disease, coverage policies and out-of-pocket costs. We developed a decision model to quantify the trade-offs between immediate, interferon-containing therapy and delayed, interferon-free therapy for patients with chronic, genotype 1 HCV infection. We projected the quality-adjusted life expectancy stratified by the presence or absence of cirrhosis for four strategies: (i) no treatment; (ii) immediate, one-time treatment with an interferon-containing regimen; (iii) immediate treatment as above with the opportunity for retreatment in patients who fail to achieve sustained virologic response with interferon-free therapy in 1 year; and (iv) delayed therapy with interferon-free therapy in 1 year. When compared to one-time immediate treatment with the interferon-containing regimen, delayed treatment with the interferon-free regimen in 1 year resulted in longer life expectancy, with a 0.2 quality-adjusted life year (QALY) increase in noncirrhotic patients, and a 1.1 QALY increase in patients with cirrhosis. This superiority in health benefits was lost when wait time for interferon-free therapy was greater than 3-3.2 years. In this modelling analysis, interferon-free therapy resulted in superior health benefits compared to immediate therapy with interferon until wait time exceeded 3-3.2 years. Such data can inform decision-making regarding treatment initiation for HCV as healthcare financing evolves.

10-nm filaments are induced to collapse in living cells microinjected with monoclonal and polyclonal antibodies against tubulin.

Cells were microinjected with four mouse monoclonal antibodies that were directed against either alpha- or beta-tubulin subunits, one monoclonal with activity against both subunits, and a guinea pig polyclonal antibody with activity directed against both subunits, to determine the effects on the distribution of cytoplasmic microtubules and 10-nm filaments. The specificities of the antibodies were confirmed by Western blots, solid phase radioimmunoassay, and Western blot analysis of alpha- and beta-tubulin peptide maps. Two monoclonals DM1A and DM3B3, an anti-alpha- and anti-beta-tubulin respectively, and the guinea pig polyclonal anti-alpha/beta-tubulin antibody (GP1T4) caused the 10-nm filaments to collapse into large lateral aggregates collecting in the cell periphery or tight juxtanuclear caps; the other monoclonal antibodies had no effect when microinjected into cells. The filament collapsing was observed to be complete at 1.5-2 h after injection. During the first 30 min after injection a few cytoplasmic microtubules near the cell periphery could be observed by fluorescence microscopy. This observation was confirmed by electron microscopy, which also demonstrated assembled microtubules in the juxtanuclear region. By 1.5 h, when most of the 10-nm filaments were collapsed, the complete cytoplasmic array of microtubules was observed. Cells injected in prophase were able to assemble a mitotic spindle, suggesting that the antibody did not block microtubule assembly. Metabolic labeling with [35S]methionine of microinjected cells revealed that total protein synthesis was the same as that observed in uninjected cells. This indicated that the microinjected antibody apparently did not produce deleterious effects on cellular metabolism. These results suggest that through a direct interaction of antibodies with either alpha- or beta-tubulin subunits, 10-nm filaments were dissociated from their normal distribution. It is possible that the antibodies disrupted postulated 10-nm filament-microtubule interactions.

Genetic basis for species vulnerability in the cheetah.

A population genetic survey of over 200 structural loci previously revealed that the South African cheetah (Acinonyx jubatus jubatus) has an extreme paucity of genetic variability, probably as a consequence of a severe population bottleneck in its recent past. The genetic monomorphism of the species is here extended to the major histocompatibility complex, since 14 reciprocal skin grafts between unrelated cheetahs were accepted. The apparent consequences of such genetic uniformity to the species include (i) great difficulty in captive breeding, (ii) a high degree of juvenile mortality in captivity and in the wild, and (iii) a high frequency of spermatozoal abnormalities in ejaculates. The species vulnerability of the cheetah was demonstrated by an epizootic of coronavirus-associated feline infectious peritonitis in an Oregon breeding colony in 1983. Exposure and spread of the coronavirus, which has a very low morbidity in domestic cats (approximately 1 percent), has decimated a heretofore productive and healthy captive population. The extreme genetic monomorphism, especially at the major histocompatibility complex, and the apparent hypersensitivity of the cheetah to a viral pathogen may be related, and provide a biological basis for understanding the adaptive significance of abundant genetic variation in outbred mammalian species.

Captive breeding of cheetahs in South Africa--30 years of data from the de Wildt Cheetah and Wildlife Centre.

The de Wildt Cheetah and Wildlife Centre was established in 1971 and the first cheetah cubs were born in 1975. During the period 1975-2005, 242 litters were born with a total of 785 cubs. Mean cub survival from 1 to 12 months and greater than 12 months of age was 71.3 and 66.2%, respectively. The majority of losses (84.9%) occurred during the first month postpartum whereas only 15.1% deaths took place between 1 and 12 months of age. Females were first bred at an age of approximately 3 years, reached maximum reproductive age at 6-8 years, where after fertility declined. Males reached peak reproduction at 6 and maintained this for up to 12 years of age. Male fertility was best correlated with sperm morphology. During recent years, for practical purposes, males were allocated to 'good' (>or=70% normal), 'fair' (40-70% normal) and 'poor' (<40% normal) categories according to sperm morphology count. The breeding males were selected from the good (preferably) and fair categories but poor category males were also used at times. Average litter sizes for 'good', 'fair' and 'poor' males were 3.44 (n = 21), 3.14 (n = 18) and 2.28 (n = 18), respectively. In females the heritability for litter size was high at 0.5848 (532 progeny, 1975-2007) and the maternal heritability for cub mortality was estimated to be 0.596. The data from the de Wildt Cheetah and Wildlife Centre and two other centres in the world (Kapama and Wassenaar) demonstrate that cheetah can be bred successfully in captivity.

ACTH stimulation test in the captive cheetah (Acinonyx jubatus).

Serum cortisol response was assessed in 8 captive cheetahs, of varying ages, after the intravenous administration of 500 microg of tetracosactide (Synacthen Depot, Novartis, Kempton Park) while maintained under general anaesthesia. In addition, 8 cheetahs were anaesthetised and given an equal volume of saline in order to establish baseline cortisol concentrations at similar stages of anaesthesia. A significant difference in the median cortisol concentration measured over time was found following ACTH administration in the ACTH group (P < 0.001). There was no difference between the median cortisol concentrations in the ACTH group at time-points 120, 150 and 180 min after ACTH stimulation (P = 0.867). Thus it appears appropriate to collect serum 120 to 180 min after tetracosactide administration to assess maximal stimulation of the adrenal in the cheetah. No statistically significant rise was seen in the anaesthetised control group following the injection of saline (P = 0.238).

Patient Perceptions of Care as Influenced by a Large Institutional Pharmacogenomic Implementation Program.

Despite growing clinical use of genomic information, patient perceptions of genomic-based care are poorly understood. We prospectively studied patient-physician pairs who participated in an institutional pharmacogenomic implementation program. Trust/privacy/empathy/medical decision-making (MDM)/personalized care dimensions were assessed through patient surveys after clinic visits at which physicians had access to preemptive pharmacogenomic results (Likert scale, 1 = minimum/5 = maximum; mean [SD]). From 2012-2015, 1,261 surveys were issued to 507 patients, with 792 (62.8%) returned. Privacy, empathy, MDM, and personalized care scores were significantly higher after visits when physicians considered pharmacogenomic results. Importantly, personalized care scores were significantly higher after physicians used pharmacogenomic information to guide medication changes (4.0 [1.4] vs. 3.0 [1.6]; P < 0.001) compared with prescribing visits without genomic guidance. Multivariable modeling controlling for clinical factors confirmed personalized care scores were more favorable after visits with genomic-influenced prescribing (odds ratio [OR] = 3.26; 95% confidence interval [CI] = (1.31-8.14); P < 0.05). Physicians seem to individualize care when utilizing pharmacogenomic results and this decision-making augmentation is perceived positively by patients.

Pharmacogenomics-Based Point-of-Care Clinical Decision Support Significantly Alters Drug Prescribing.

Changes in behavior are necessary to apply genomic discoveries to practice. We prospectively studied medication changes made by providers representing eight different medicine specialty clinics whose patients had submitted to preemptive pharmacogenomic genotyping. An institutional clinical decision support (CDS) system provided pharmacogenomic results using traffic light alerts: green = genomically favorable, yellow = genomic caution, red = high risk. The influence of pharmacogenomic alerts on prescribing behaviors was the primary endpoint. In all, 2,279 outpatient encounters were analyzed. Independent of other potential prescribing mediators, medications with high pharmacogenomic risk were changed significantly more often than prescription drugs lacking pharmacogenomic information (odds ratio (OR) = 26.2 (9.0-75.3), P < 0.0001). Medications with cautionary pharmacogenomic information were also changed more frequently (OR = 2.4 (1.7-3.5), P < 0.0001). No pharmacogenomically high-risk medications were prescribed during the entire study when physicians consulted the CDS tool. Pharmacogenomic information improved prescribing in patterns aimed at reducing patient risk, demonstrating that enhanced prescription decision-making is achievable through clinical integration of genomic medicine.

Enlargement of the Internal Auditory Canal and Associated Posterior Fossa Anomalies in PHACES Association.

We noted enlargement of the internal auditory canal in several of our patients with posterior fossa malformations, hemangiomas, arterial anomalies, cardiac defects, eye abnormalities, and sternal or supraumbilical defects (PHACES) association and hence evaluated children with PHACES for the presence of an enlarged internal auditory canal and potential associated findings, including infantile hemangioma within the internal auditory canal, to understand the genesis of this enlargement. We reviewed our records to identify children with PHACES association who had been evaluated with MR imaging at our institutions. Imaging was reviewed for abnormal enhancement in the internal auditory canal, internal auditory canal enlargement, cerebellar hypoplasia, prominence of the petrous ridge, and deformity of the calvarium. We raise the possibility of an association between enlargement of the internal auditory canal in PHACES and a generalized malformation of the posterior fossa with cerebellar and calvarial hypoplasia.

Handling-induced stress and mortalities in African wild dogs (Lycaon pictus).

Recently it was suggested that the handling of wild dogs (Lycaon pictus) by researchers in the Serengeti ecosystem created stress, resulting in the reactivation of latent rabies viruses in carrier animals. We present data from ongoing studies on free-ranging and captive wild dogs elsewhere in Africa which do not support this hypothesis. Cortisol profiles suggest that immobilization of wild dogs does not cause the chronic stress required for stress-reactivation of latent viruses. Furthermore, there is no evidence of handling-related mortalities in wild dogs: the survivorship of unhandled and handled free-ranging wild dogs did not differ and no captive animals died within a year of handling (immobilization and/or vaccination against rabies). We suggest that the mortalities observed in Tanzania were due to an outbreak of a disease which rabies vaccination was unable to prevent. Intensive monitoring and active management research programmes on wild dogs are essential as without these, critically endangered wild dog populations have little hope of survival.

Pituitary and gonadal response to LH releasing hormone administration in the female and male cheetah.

Luteinizing hormone releasing hormone (LHRH, 50 micrograms) or saline was administered (i.m.) to adult female and male cheetahs under anaesthesia to evaluate pituitary and gonadal response. Serum LH levels did not fluctuate over a 120-min sampling period in saline-treated animals. Serum LH concentrations were raised (P less than 0.05) in both female and male cheetahs after LHRH injection, the temporal response being similar to previously reported results in unanaesthetized, domestic carnivores. The magnitude of the LHRH-induced LH response was sex-dependent. Over a 120-min post-injection period both saline control and LHRH-induced LH levels were about twofold greater in males than females. Although LHRH had no acute influence on ovarian oestradiol-17 beta production in the female, serum testosterone levels were raised (P less than 0.05) in male cheetahs by 60 min after treatment. This study (1) provides introductory endocrine information on the cheetah, an endangered species, and (2) indicates that exogenous LHRH is effective in acutely altering pituitary (female) and pituitary/gonadal (male) function in an anaesthetized, non-domestic felid.

Perspective and the measurement of costs and benefits for cost-effectiveness analysis in schizophrenia.

A valid and compelling cost-effectiveness analysis of psychopharmacologic treatment of schizophrenia requires the application of analytically rigorous methods. All cost-effectiveness analyses must consider the issue of perspective as the well as the appropriate measurement of benefits and costs. Many of these issues are particularly difficult to address in the case of schizophrenia. Since costs may be borne by a wide range of parties, the choice of perspective is of critical importance. The fact that treatments for schizophrenia can extend life and the complexities raised by taking a broad perspective on the benefits and costs of treating schizophrenia can create challenges in the measurement of both benefits and costs. The measurement of benefits through quality-adjusted life years is also crucial in demonstrating the cost-effectiveness of treatments for schizophrenia, but is challenging because of the difficulty of measuring quality of life in schizophrenic patients. Attention to these important methodological issues is essential if cost-effectiveness analyses are to be useful in shepherding scarce resources to worthwhile treatments for patients with schizophrenia.

Sterile hypopyon following intraocular lens surgery.

Energy-dispersive x-ray analysis (EDXA) was used to study nine intraocular lenses from one manufacturer. Residual polishing compound was found on two of three dry-sterilized lenses from a "hot lot" associated with a high incidence of sterile hypopyon. Similar material was not present on normal lenses. This polishing compound was apparently fused to the lens surface, preventing its removal by ultrasonic cleaning. In addition, three wet-sterilized lenses were found to be covered with small crystals containing barium. These crystals apparently resulted from leaching of the glass storage vial by the caustic storage fluid. It is suggested that some cases of sterile hypopyon following intraocular lens surgery may be caused by residual polishing compound present on the lens surface.

Particulate contamination in disposable corneal trephines.

In two cases scheduled for corneal transplantation, edges of donor corneal buttons were discolored by a black contaminant transferred from the disposable trephines. Trephines from two different manufacturers produced this same problem. Scanning electron microscopy and energy-dispersive x-ray analysis indicated that the contaminant was a mixture of stainless steel particles from the trephine and silicon carbide abrasive used in sharpening.

A miniature compliance monitor for eyedrop medication.

We developed an eyedrop medication monitor that electronically records the date and time of each medication administration over a six-week period. It records a medication usage in a 15-minute interval when the cap is removed from the bottle and the bottle is inverted. The electronic components housed inside the bottle weigh 7.5 g, including the batteries, and the total volume of the circuit is 7.5 cc. The monitor resembles commercially available 30-mL eyedrop bottles in size, shape, and weight. The monitor is accurate when tested against known patterns of usage. The electronic eyedrop monitor should be useful in assessing compliance with eyedrop medications.

Body-mass dependence of age-related deterioration in human muscular function.

Maximal anaerobic power of human muscles declines with increasing chronological age and is correlated with body mass. This study investigated whether the rate of deterioration in human muscular function among trained weight lifters is also correlated with body mass. Cross-sectional analysis of performance data of over 1,100 Masters competitors in Olympic-style weight lifting was carried out; eight body-weight classes and six age groups were represented. Two-lift total data (sum of snatch and clean and jerk lifts) were analyzed. Mean deterioration rates in the performance of athletes of widely diverse body masses were compared over the following age ranges: 42-57, 42-62, and 42-67 yr. No statistically significant correlation (P < 0.05) was found between rate of performance decline and body mass. The relationship between body mass and the magnitude of age-related variation of deterioration rate was also studied; no significant correlation was found. Previous studies have demonstrated that performance in Olympic-style weight lifting is correlated with maximal anaerobic muscular power. This leads us to suggest that the age-related deterioration rate of anaerobic power in trained subjects may not be correlated with the body mass of the individual.