Dried Blood Spot Analyses for the Diagnosis of Anti-cytokine Autoantibodies

Background: High-titer neutralizing anti-cytokine autoantibodies have been shown to be involved in several acquired diseases, including pulmonary alveolar proteinosis, cryptococcal meningitis, and disseminated/extrapulmonary Nocardia infections (anti-GM-CSF autoantibodies), disseminated mycobacterial disease (anti-IFN-gamma autoantibodies), and some cases of severe COVID-19 infection (anti-type 1 interferons). Currently, patient blood samples are shipped via courier and require temperaturecontrolled conditions for transfer. This method is expensive and requires patients to have access to medical personnel to draw the blood. However, the well-established technique of collecting blood on a paper card as a dried blood spot (DBS) for diagnosis offers a point of care alternative which can be performed with a simple finger prick. This method is less invasive, cheaper, and allows for easy transport of patient samples. Method(s): 30 uL of whole blood from patients was blotted on filter paper and stored at 4C until use. The filter paper was hole punched and each punched spot was eluted with 150 uL of a 0.05% Tween PBS solution at room temperature overnight. The eluate was screened for anti-cytokine autoantibodies using a particle-based approach. Patient plasma was also screened in conjunction for comparison. Result(s): We confirmed the presence of autoantibodies in the DBS eluate from 4 previously diagnosed patients with anti-GM-CSF autoantibodies and 2 patients with anti-IFN-gamma autoantibodies. Functional studies showed the DBS eluate from a patient with anti-GM-CSF autoantibodies was able to block GM-CSF-induced STAT-5 phosphorylation in normal PBMC. As a proof of concept and to increase the number of patients evaluated, we also confirmed the presence of anti-cytokine autoantibodies using dried plasma eluate from 9 patients with known anti-GM-CSF autoantibodies and 9 patients with anti-IFN-gamma autoantibodies. Levels detected in DBS analyses were comparable to the levels found in plasma from the same patients not subjected to blotting and elution. Temperature studies showed that the autoantibodies were detected at similar levels when stored at 4C, 25C, and 40C for a week. Conclusion(s): The diagnosis of pathogenic anti-cytokine autoantibodies should be considered in the context of unusual or adult-onset infections, and screening for this diagnosis can be performed with dried blood spot testing.Copyright © 2023 Elsevier Inc.

Correlation between levels of anti-cytokine antibodies, recombination activity of the mutant RAG proteins and clinical phenotype in patients with RAG deficiency

RAG mutations cause various phenotypes: SCID, Omenn syndrome (OS), leaky SCID (LS) and combined immunodeficiency (CID). We had previously reported autoantibodies targeting IFN-alpha, IFN-omega in patients with RAG deficiency. However, how the presence of such antibodies correlated with the severity of the clinical phenotype and with the recombination activity of the mutant proteins was unknown. To address this, we have studied anti-cytokine antibodies in 118 patients with RAG defects (SCID, n = 28;OS, n = 29;LS, n = 29;CID, n = 32), and in 42 controls (protocols NCT03394053 and NCT03610802). RAG mutant proteins associated with CID and LS retained 35.6 +/- 4.3 (mean +/- SE) and 29.8 +/- 5.1% recombination activity respectively, compared to wildtype protein, which was significantly higher than the recombination activity of the mutant RAG proteins associated with OS (4.1 +/- 1.5%) and SCID (5.7 +/- 2.1%) (p < 0.0001). Among 32 CID patients, 24 tested positive for anti-IFN-alpha and 21 for anti-IFN-omega antibodies. Among 29 LS patients, 15 had high levels of anti-IFN-alpha and 13 of anti-IFN-omega antibodies. A minority of the CID and LS patients had also high levels of anti-IFN-beta and anti-IL-22 antibodies. By contrast, none of the OS patients tested positive for anti-cytokine antibodies. High levels of anti-IFN-alpha and anti-IFN-omega antibodies correlated with their neutralizing activity as demonstrated in vitro by analysis of STAT1 phosphorylation upon stimulation of healthy donor monocytes in the presence of the appropriate cytokine and patient's or control plasma. Severe viral infections were recorded in 26/41 patients with CID and LS who tested positive and in 7/20 who tested negative for anti-IFN-alpha and/or anti-IFN-omega antibodies (p <0.05). Among those with anti-IFN antibodies, EBV (n = 8), CMV (n = 6), HSV (n = 5), VZV (n = 4) and adenovirus (n = 4) infections were more common. Two patients had COVID-19, which was fatal in one. Presence of the rubella virus was documented in 5 patients with anti-type I IFN antibodies. These results demonstrate that high levels of neutralizing anti-IFN-alpha and anti-IFN-omega antibodies are common in patients with RAG mutations manifesting as CID and LS, but not in those with OS, and that their presence is associated with a high risk of serious viral infections.Copyright © 2023 Elsevier Inc.

A student's lesson in healthcare disparities

This narrative was born out of a desire to examine the effects of healthcare disparities among minority populations. As a medical student, I had the opportunity to spend a 4-week rotation working with physicians specializing in palliative care during what is arguably the most challenging public health crisis in over a century. This provided a unique perspective that allowed the observation of the intersection of healthcare systems with underserved and vulnerable minority populations, and palliative medicine. It also allowed us to observe the negative consequences it has had, particularly during a hard-hitting global pandemic. The paper gives a brief introduction to the problem of healthcare disparities as described by the WHO and CDC. We discuss some of the statistical data that show how certain demographics like workers in service industries, or meat-packing facilities are more likely to contract the COVID-19 virus, and how these same populations are disproportionately affected by the pandemic due to their limited access to healthcare systems. We then discuss the case of a COVID-19 patient that was treated by a multidisciplinary team during this period. This patient, like many others, was an immigrant with limited proficiency in the English language, as well as a limited medical education. We provide details about his medical course during his admission, and we try to highlight some of the pitfalls in the healthcare system as it relates to this patient's prognosis and healthcare outcome. © The Author(s), 2020.

The effectiveness of in-person versus remote group couples therapy for the treatment of low sexual desire or frequency

Low/no sexual desire/frequency or sexual desire discrepancies are one of the most common presenting problems in sex therapists' offices and among the hardest to treat. Most interventions target the identified patient (i.e., typically the woman with low desire), most recently via biomedical therapies (i.e., flibanserin and bremelanotide). Few interventions to date have shown consistent and successful improvements in this population of distressed couples. To determine whether a group couples sex therapy intervention, offered in-person or via teletherapy, could help couples distressed by low/no sexual desire/frequency. Couples were seen in groups of 4-6 couples (i.e,. 8-12 individuals) for an 8-week, 16-hour intervention led by 13 co-therapist dyads (i.e., 26 licensed clinicians) in 2 countries. Individuals completed the New Sexual Satisfaction Scale (NSSS) plus 3 additional items at assessment, pre-test, post-test and at 6-month follow-up. A total of 107 couples (i.e., 214 individuals) completed the intervention from pre-test to post-test, 75 of whom completed the intervention in-person and 32 via teletherapy during COVID-19. This included 94 heterosexual couples and 13 LGBTQ couples. Of these 107 couples, 42 (i.e., the waitlist control) also completed the assessment at least one month prior to group therapy and 51 couples completed the 6-month follow-up. Paired samples t-tests were conducted between assessment and pre-test, between pre-test and post-test and between pre-test and follow-up. Paired samples t-tests were also conducted between couples' mean scores on individual items from pre-test to post-test and from pre-test to follow-up. An independent samples t-test was conducted on the mean differences in outcomes between couples who completed the in-person intervention versus those who completed it via teletherapy. Participants also provided written feedback regarding changes in their relationships resulting from therapy. No changes occurred on waitlist control scores from assessment to pre-test. For all couples, mean total scores on the NSSS increased by an average of 13.1 ± 10.7 points from pre-test to post-test. This increase in scores was equally significant for groups conducted in-person (p <.001, d = 1.2), and via teletherapy (p <.001, d = 1.3). The amount of change found in couples who underwent the in-person intervention versus those who participated in online group therapy was equivalent. There was a statistically significant increase in scores between pre-test and 6-month follow-up (p <.001, d = 0.6), suggesting that the effects of the intervention were enduring. In addition, there was a statistically significant difference from pre-test to post-test for various individual items on the NSSS, most notably in satisfaction with individuals' overall sex lives (p <.001, d = 0.9). In their feedback, participants described improvements in emotional connection, embodiment, being "in the moment", playfulness, enjoyment, authenticity, as well as increased comfort with communication in general, about sex and at times of conflict. Group couples therapy for low/no sexual desire/frequency, offered in person or via teletherapy, is an accessible and effective way of enhancing sexual intimacy and thereby ameliorating sexual desire discrepancies for distressed couples. Work supported by industry: no. [ FROM AUTHOR] Copyright of Journal of Sexual Medicine is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

Structural basis of SARS-CoV-2 Omicron immune evasion and receptor engagement

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) Omicron variant of concern evades antibody-mediated immunity that comes from vaccination or infection with earlier variants due to accumulation of numerous spike mutations. To understand the Omicron antigenic shift, we determined cryo-electron microscopy and x-ray crystal structures of the spike protein and the receptor-binding domain bound to the broadly neutralizing sarbecovirus monoclonal antibody (mAb) S309 (the parent mAb of sotrovimab) and to the human ACE2 receptor. We provide a blueprint for understanding the marked reduction of binding of other therapeutic mAbs that leads to dampened neutralizing activity. Remodeling of interactions between the Omicron receptor-binding domain and human ACE2 likely explains the enhanced affinity for the host receptor relative to the ancestral virus.

Type i Interferon Autoantibodies Are Detected in Those with Critical COVID-19, Including a Young Female Patient

Background. Approximately 10-20% of patients with critical COVID-19 harbor neutralizing autoantibodies (auto-Abs) that target type I interferons (IFN), a family of cytokines that induce critical innate immune defense mechanisms upon viral infection. Studies to date indicate that these auto-Abs are mostly detected in men over age 65. Methods. We screened for type I IFN serum auto-Abs in sera collected < 21 days post-symptom onset in a subset of 103 COVID-19 inpatients and 24 outpatients drawn from a large prospective cohort study of SARS-CoV-2 infected patients enrolled across U.S. Military Treatment Facilities. The mean age of this n = 127 subset of study participants was 55.2 years (SD = 15.2 years, range 7.7 - 86.2 years), and 86/127 (67.7%) were male. Results. Among those hospitalized 49/103 (47.6%) had severe COVID-19 (required at least high flow oxygen), and nine subjects died. We detected neutralizing auto-Abs against IFN-α, IFN-ω, or both, in four inpatients (3.9%, 8.2% of severe cases), with no auto-Abs detected in outpatients. Three of these patients were white males over the age of 62, all with multiple comorbidities;two of whom died and the third requiring high flow oxygen therapy. The fourth patient was a 36-year-old Hispanic female with a history of obesity who required mechanical ventilation during her admission for COVID-19. Conclusion. These findings support the association between type I IFN auto-antibody production and life-threatening COVID-19. With further validation, reliable high-throughput screening for type I IFN auto-Abs may inform diagnosis, pathogenesis and treatment strategies for COVID-19, particularly in older males. Our finding of type I IFN auto-Ab production in a younger female prompts further study of this autoimmune phenotype in a broader population.

COMPARING TECHNOLOGY USE BETWEEN OLDER TEENAGERS AND MILLENNIALS, TESTING PREDICTIVE MODELS USING TECHNOLOGY MEDIATOR VARIABLES, AND ASSESSING AND EXAMINING THE IMPACT OF INTERVENTIONS TO REDUCE OBSESSIVE SMARTPHONE USAGE

Objectives: The aims of this session are to: 1) compare self-report and app-reported measures of smartphone use between older teenagers and millennials;2) examine the impact of affective and cognitive variables in predicting a variety of constructs (sleep quality, academic performance, stress, anxiety, depression) as mediated by technology use;and 3) assess the efficacy of interventions to reduce technology use. Note that some observations were collected before and during COVID-19 at-home instruction, providing a serendipitous opportunity to examine smartphone usage as a function of the pandemic educational demands. This was not a study variable and involved limited data. Methods: For each study, online surveys assessed self-reported technology use, app-reported smartphone use, social media use, digital metacognition, executive functioning problems, technological anxiety (nomophobia), and multitasking preference. Most studies also assessed a variety of affective, cognitive, and technology use variables. Some included an intervention to reduce screen time. Results: Although the most recent data are currently being analyzed, studies demonstrated that both older teenagers (17-18 years) and millennials (Mage = 25 years) showed the same pattern of daily smartphone unlocks and daily smartphone minutes, indicating that they averaged approximately 70 daily unlocks for 265 smartphone minutes. Interventions changed smartphone use during the intervention but reverted to baseline soon thereafter. Models demonstrated the impact of both cognitive and affective variables on sleep, academic performance and depression, stress and anxiety as mediated by smartphone use, and social media use and digital metacognition for millennials and older teenagers. Conclusions: 1) Smartphone usage is increasing for both millennials and older teenagers. 2) Affective and cognitive variables do indeed predict sleep quality, academic performance and stress, and anxiety and depression, and they are powerfully mediated by social media use, smartphone use, and digital metacognition. 3) Efforts to ameliorate these smartphone usage behaviors failed to enact even temporary changes when the interventions were removed. AD, DDD, MED

Impacts of COVID-19 on aquatic food supply chains in Bangladesh, Egypt, India, Myanmar, Nigeria and Timor-Leste, February-April 2020. (Program report.)

A multi-country survey of fish supply chain actors in Bangladesh, India, Myanmar, Nigeria, Egypt and Timor Leste has been conducted to evaluate the availability and price of aquatic foods and production inputs as a form of assessment of the evolving impacts of the COVID-19 pandemic. Respondents were selected based on snowball sampling which included: hatcheries (n=78), feedmills (n=26), non-pelleted feed sellers (n=31), pelleted feed sellers (n=64), farmers(n=233) processors (n=39), traders (n=85), retailers (n=78) and fishers (n=131). Results showed that COVID-19 contributed to: (1) a decreased hiring of daily labor as the average daily wages increase;(2) a decrease of bought inputs as access to transport, inputs, and buyers also declined;(3) significant drop in production and sales in various supply chains;and (4) big drops in sales and input procurement across farmers, fishers, processors and traders. Policy recommendations are as follows: provide financial support to supply chain actors, assure smooth flows of products and inputs, and assure constant demand.

COVID-19 impacts and adaptations in Asia and Africa's aquatic food value chains. (Working Paper: FISH-2021-02.)

The COVID-19 pandemic is a systemic shock that affects all areas of the global food system. A growing range of impacts on aquatic food producers, value chain actors and consumers is evident. In response, the report provides the impacts of COVID-19 on aquatic food value chains in Bangladesh, Egypt, India, Myanmar and Nigeria. Results show that: (1) COVID-19 and associated containment measures severely disrupted aquatic food value chains, but effects on supply were relatively short-lived;(2)Demand for aquatic foods has yet to recover to pre-pandemic levels;(3) prices of aquatic foods have downward trend while prices of manufactured feeds have risen;and (4) COVID-19 has exacerbated pre-existing inequalities. As COVID-19 pandemic reversed years of progress on key human development indicators, it is important to revitalize aquatic food value chains to protect livelihoods and human nutrition. The paper also provides policy recommendations for both supply and demand sides.

Preexisting autoantibodies to type I IFNs underlie critical COVID-19 pneumonia in patients with APS-1

Patients with biallelic loss-of-function variants of AIRE suffer from autoimmune polyendocrine syndrome type-1 (APS-1) and produce a broad range of autoantibodies (auto-Abs), including circulating auto-Abs neutralizing most type I interferons (IFNs). These auto-Abs were recently reported to account for at least 10% of cases of life-threatening COVID-19 pneumonia in the general population. We report 22 APS-1 patients from 21 kindreds in seven countries, aged between 8 and 48 yr and infected with SARS-CoV-2 since February 2020. The 21 patients tested had auto-Abs neutralizing IFN-a subtypes and/or IFN-;one had anti-IFN-beta and another anti-IFN-T, but none had anti-IFN-. Strikingly, 19 patients (86%) were hospitalized for COVID-19 pneumonia, including 15 (68%) admitted to an intensive care unit, 11 (50%) who required mechanical ventilation, and four (18%) who died. Ambulatory disease in three patients (14%) was possibly accounted for by prior or early specific interventions. Preexisting auto-Abs neutralizing type I IFNs in APS-1 patients confer a very high risk of life-threatening COVID-19 pneumonia at any age.

Improving families' health, education, and financial outcomeswith an incentives-based savings program in a pediatric clinic

Background: Prior to COVID-19, two out of ve people in the US could not cover a $400 emergency. Now,many more families are struggling nancially. Families with low income often don't seek needed healthcare,risking poor health outcomes. Minority families, in particular, suffer health inequities stemming fromdisparities in social capital, income, and education. Higher education improves long-term economic success,but low-income families have difficulty saving for their children's futures. Children's Savings Account (CSA)programs, which provide higher education savings to children in early childhood, have increased families'college expectations and improved mothers' mental health and children's socio-emotional development.Methods: We assessed parents' perceptions of and access to preventive healthcare, as well as the educationalgoals they have for their children. We conducted qualitative interviews with 13 parents meeting the followingcriteria: (1) at least one child age 3 or younger, (2) maximum income at 185% of the federal poverty level, and(3) no parent with an advanced degree (e.g. master's). We will interview seven more parents by December 2020. Meanwhile, we designed Early Bird, a rst-of-its-kind health clinic-based CSA program that rewardsfamilies for achieving healthy milestones-such as attending pediatrician and dentist appointments, meetingwith a nancial coach, and enrolling in pre-Kindergarten-with scholarship funds in their children's CSAs. Weare launching a 3-year longitudinal randomized study to evaluate this novel model. Results: All parentsinterviewed would participate in a milestone-based CSA program through their health clinic. All hoped theirchild(ren) would attend college, 85% perceived nancial barriers to higher education, and 69% worried thatnot attending college would limit their child's career. Only 23% of participants had savings for college.Participants' self-described ethnicities were 85% Hispanic or Latino, 7.5% Black or African American, 7.5%American Indian or Alaska Native, and 7.5% White/Caucasian.(1) Philanthropic funds were raised to supportthe launch of Early Bird's pilot serving 300 children, including scholarships up to $500 per child. Contractedpartners include a federally-qualied health center, a nancial coaching service provider, a 529 accountmanagement system provider, and a local nonprot that will administer the scholarship accounts. Theprogram will launch in 2020. Discussion: Parents with low income desire higher education for their childrenbut struggle to save money. This new model aligns short-term achievements during early childhood in health,education, and family nances with long-term goals for higher education and career success. This studyinforms a replicable model with potential to improve health, education, and nancial outcomes nationally.Early Bird aligns many milestone achievements with the priorities of health insurance payers, which may aidlong-term nancial sustainability. Feasibility studies are needed to further assess the model's viability indiffering clinical settings. (1) Totals more than 100% due to multi-select answer format.

Impact of COVID-19 on Outcomes and Productivity in a Gynecologic Oncology and Minimally Invasive Surgery Practice

Study Objective To determine the impact of COVID-19 on patients undergoing surgery. Design Retrospective review. Setting Community hospital and ambulatory practice in New York near the epicenter of the COVID-19 pandemic. Patients or Participants Surgical volumes were reviewed for years 2019-2020. Interventions Seventy-three charts were assessed for COVID-19 related outcomes during a 14-week period, beginning February 17th, 2020. Measurements and Main Results During the study period, gynecologic oncology and minimally invasive surgery activity decreased by 50%. This resulted in economic and clinical disruption. Other surgical divisions showed similar case decreases (34 – 64%) except for otolaryngology which increased by 48%. Seventy-one surgeries were completed in our practice during the study period. Elective cases were restricted on March 7th. Afterward, indications for surgery were malignancy (43.2%), rule out malignancy (27.0%), heavy bleeding (21.6%), and pain (8.1%). All patients were asymptomatic for COVID-19 associated symptoms during preoperative evaluations. Mandatory day-of-surgery COVID-19 PCR testing commenced on April 6th. Prior to this, 49 surgeries were completed. Afterward, 4 of the remaining 21 cases (18%) were cancelled due to positive testing. Of these, 3 tested positive on day of surgery, 1 self-tested positive due to community exposure. All 4 patients remained asymptomatic. Of the 71 patients, 83% were discharged on the same day or on postoperative day one (POD). Postoperatively, 6 patients reported mild COVID-19 symptoms (cough, fever, shortness of breath). Of these, 1 patient tested negative and 5 were not tested. Additionally, 1 patient tested positive remote from surgery (POD #30). Surgeons tested negative for COVID-19 antibodies, and all office staff were asymptomatic. Conclusion Asymptomatic COVID-19 patients were encountered in the preoperative setting. No symptomatic cases of nosocomial COVID-19 infection were identified. Clinical care and surgery appear safe provided there is appropriate utilization of personal protective equipment (PPE). Gynecologic surgical services may be safely performed during a pandemic with appropriate PPE and safety measures.