Human IRF1 governs macrophagic IFN-γ immunity to mycobacteria.

Inborn errors of human IFN-γ-dependent macrophagic immunity underlie mycobacterial diseases, whereas inborn errors of IFN-α/ß-dependent intrinsic immunity underlie viral diseases. Both types of IFNs induce the transcription factor IRF1. We describe unrelated children with inherited complete IRF1 deficiency and early-onset, multiple, life-threatening diseases caused by weakly virulent mycobacteria and related intramacrophagic pathogens. These children have no history of severe viral disease, despite exposure to many viruses, including SARS-CoV-2, which is life-threatening in individuals with impaired IFN-α/ß immunity. In leukocytes or fibroblasts stimulated in vitro, IRF1-dependent responses to IFN-γ are, both quantitatively and qualitatively, much stronger than those to IFN-α/ß. Moreover, IRF1-deficient mononuclear phagocytes do not control mycobacteria and related pathogens normally when stimulated with IFN-γ. By contrast, IFN-α/ß-dependent intrinsic immunity to nine viruses, including SARS-CoV-2, is almost normal in IRF1-deficient fibroblasts. Human IRF1 is essential for IFN-γ-dependent macrophagic immunity to mycobacteria, but largely redundant for IFN-α/ß-dependent antiviral immunity.

Humans with inherited T cell CD28 deficiency are susceptible to skin papillomaviruses but are otherwise healthy.

We study a patient with the human papilloma virus (HPV)-2-driven "tree-man" phenotype and two relatives with unusually severe HPV4-driven warts. The giant horns form an HPV-2-driven multifocal benign epithelial tumor overexpressing viral oncogenes in the epidermis basal layer. The patients are unexpectedly homozygous for a private CD28 variant. They have no detectable CD28 on their T cells, with the exception of a small contingent of revertant memory CD4+ T cells. T cell development is barely affected, and T cells respond to CD3 and CD2, but not CD28, costimulation. Although the patients do not display HPV-2- and HPV-4-reactive CD4+ T cells in vitro, they make antibodies specific for both viruses in vivo. CD28-deficient mice are susceptible to cutaneous infections with the mouse papillomavirus MmuPV1. The control of HPV-2 and HPV-4 in keratinocytes is dependent on the T cell CD28 co-activation pathway. Surprisingly, human CD28-dependent T cell responses are largely redundant for protective immunity.

Human T-bet Governs Innate and Innate-like Adaptive IFN-γ Immunity against Mycobacteria.

Inborn errors of human interferon gamma (IFN-γ) immunity underlie mycobacterial disease. We report a patient with mycobacterial disease due to inherited deficiency of the transcription factor T-bet. The patient has extremely low counts of circulating Mycobacterium-reactive natural killer (NK), invariant NKT (iNKT), mucosal-associated invariant T (MAIT), and Vδ2+ γδ T lymphocytes, and of Mycobacterium-non reactive classic TH1 lymphocytes, with the residual populations of these cells also producing abnormally small amounts of IFN-γ. Other lymphocyte subsets develop normally but produce low levels of IFN-γ, with the exception of CD8+ αß T and non-classic CD4+ αß TH1∗ lymphocytes, which produce IFN-γ normally in response to mycobacterial antigens. Human T-bet deficiency thus underlies mycobacterial disease by preventing the development of innate (NK) and innate-like adaptive lymphocytes (iNKT, MAIT, and Vδ2+ γδ T cells) and IFN-γ production by them, with mycobacterium-specific, IFN-γ-producing, purely adaptive CD8+ αß T, and CD4+ αß TH1∗ cells unable to compensate for this deficit.

Incarcerated gravid uterus: a new treatment using the transvaginal ultrasound probe and narrative literature review.

BACKGROUND: 'Incarcerated gravid uterus' is a morbid complication that occurs in 1 in 3000 pregnancies. It is characterized by failure of a retropositioned uterus to become an abdominal organ between 12 to 14 weeks of gestation. If maternal symptoms develop or gestational age surpasses 14 to 16 weeks, replacement of a retropositioned uterus is recommended to reduce adverse outcomes. Previously described techniques for management include passive reduction, digital replacement, or more invasive methods such as laparoscopy, laparotomy, or sigmoidoscopy. These methods are either minimally effective, painful, or risky. OBJECTIVE: The objective of this report is to describe our clinical experience with a new minimally invasive technique that uses the transvaginal ultrasound probe for uterine replacement in cases of incarceration, to conduct a narrative literature review on 'incarcerated gravid uterus,' and to propose an algorithm for management of this condition. STUDY DESIGN: This is a case series of 8 patients with an incarcerated gravid uterus who were managed with the transvaginal ultrasound probe technique at one academic medical institution between March 2020 and July 2023, as well as a narrative review of the literature on 'incarcerated gravid uterus.' PubMed, Google Scholar, and Ovid MEDLINE databases were searched for the terms "incarcerated gravid uterus," "uterine incarceration," "uterine sacculation," and "retroverted uterus" up to April 2024. RESULTS: The transvaginal ultrasound probe technique resulted in successful uterine replacement, with resolution of symptoms, in all 8 patients. All pregnancies resulted in live births with good neonatal outcomes-7 out of 8 patients delivered at term, and 1 delivered in the late preterm period. CONCLUSION: Our proposed technique for treatment of an incarcerated gravid uterus with the transvaginal ultrasound probe is simple, minimally invasive and effective. Based on our experience and the narrative literature review, an algorithm for the management of an incarcerated gravid uterus is proposed.

Environmental Sustainability in Dermatological Surgery. Part 2: Reducing Activity and Future Ecological Strategies.

This two-part review addresses the pressing need for environmental sustainability in dermatological surgery, driven by the NHS's commitment to net-zero emissions. Part 2 of this review extends the discussion of sustainability in dermatological surgery by focusing on system-wide changes in service delivery and identifying future opportunities for reducing environmental impact. Building on the strategies outlined in Part 1, which explored low-carbon alternatives and operational resource optimisation, Part 2 advocates for a comprehensive shift in the skin surgery service. Key strategies include reducing overall surgical activity, advancing research and innovation, and enhancing management practices to align with sustainability goals. Reducing surgical activity mainly involves the prevention of skin cancers, in addition to optimising current patient pathways and empowering patients to take ownership of their follow-up. Outside of immediate clinical decision-making at the individual level, the review highlights the importance of managerial policy, procurement practices and supply chain factors in driving broader national and international sustainability efforts. Advancing the sustainability agenda will also require targeted research and innovation, particularly in digital health solutions using evidence-based practices. By integrating these strategies, this review aims to provide a framework for reducing the environmental footprint of dermatological surgery and advancing towards a more sustainable healthcare system.

Environmental Sustainability in Dermatological Surgery. Part 1: Reducing Carbon Intensity.

This two-part review addresses the pressing need for environmental sustainability in dermatological surgery, driven by the NHS's commitment to net-zero emissions. Part 1 focuses on strategies to reduce the carbon intensity of dermatological procedures by adopting low-carbon alternatives and optimising operational resource usage. Key strategies for a system-wide reduction in environmental impact include using leveraging local suppliers to reduce transport emissions, streamlining care models, promoting efficient waste management, and using mindful prescribing practices. Another aspect is integrating sustainability into dermatological education whilst minimising the carbon footprint of surgical education. Additionally, the review provides a comprehensive overview of optimising resource use in dermatological surgery, focusing on efficient management of consumables, equipment, and energy. This includes recycling, waste segregation, transitioning to reusable personal protective equipment and surgical instruments, and applying energy-saving and sustainable water use practices. By implementing these strategies, dermatological surgery can significantly reduce its environmental impact while upholding high standards of patient care.

Inherited deficiency of stress granule ZNFX1 in patients with monocytosis and mycobacterial disease.

Human inborn errors of IFN-γ underlie mycobacterial disease, due to insufficient IFN-γ production by lymphoid cells, impaired myeloid cell responses to this cytokine, or both. We report four patients from two unrelated kindreds with intermittent monocytosis and mycobacterial disease, including bacillus Calmette-Guérin-osis and disseminated tuberculosis, and without any known inborn error of IFN-γ. The patients are homozygous for ZNFX1 variants (p.S959* and p.E1606Rfs*10) predicted to be loss of function (pLOF). There are no subjects homozygous for pLOF variants in public databases. ZNFX1 is a conserved and broadly expressed helicase, but its biology remains largely unknown. It is thought to act as a viral double-stranded RNA sensor in mice, but these patients do not suffer from severe viral illnesses. We analyze its subcellular localization upon overexpression in A549 and HeLa cell lines and upon stimulation of THP1 and fibroblastic cell lines. We find that this cytoplasmic protein can be recruited to or even induce stress granules. The endogenous ZNFX1 protein in cell lines of the patient homozygous for the p.E1606Rfs*10 variant is truncated, whereas ZNFX1 expression is abolished in cell lines from the patients with the p.S959* variant. Lymphocyte subsets are present at normal frequencies in these patients and produce IFN-γ normally. The hematopoietic and nonhematopoietic cells of the patients tested respond normally to IFN-γ. Our results indicate that human ZNFX1 is associated with stress granules and essential for both monocyte homeostasis and protective immunity to mycobacteria.

Demographic and clinical correlates of depression among older adults with arthritis in Nigeria.

Background: Older adults have a high prevalence of chronic conditions like arthritis with morbidities, especially depression ranging up to 40% - 70%. Therefore, it is important to explore depression in older adults with arthritis. Aim: This study aimed to determine if any demographic and clinical factors are associated with depression in older adults aged ≥ 60 years with arthritis attending a rheumatology clinic. Setting: This is a cross-sectional study conducted over 6 months among 127 older adults on follow-up care in a university teaching hospital in the North-Eastern region of Nigeria. Methods: A clinical proforma with information about the type of arthritis, duration of illness, hospitalisation, use of medications, co-morbidity was utilised for the data collection. The Geriatric Depression Scale (GDS-30), sociodemographic questionnaire and clinical proforma were administered. Data were analysed using Statistical Product and Service Solutions (SPSS) version 26.0 with the level of significance set as 0.05. Results: The mean age (± standard deviation [s.d.]) was 66.6 (± 5.5) years, with males constituting 57.5%. The prevalence of depression was 57.8%. Osteoarthritis 30.2%, while 69.8% had rheumatoid arthritis. Sociodemographic factors associated with depression include age (p = 0.049), marital status (p = 0.001), and level of education (p = 0.001). Duration of illness (p = 0.02), hospitalisation (p = 0.03), and number of medications (p = 0.01) were clinical factors associated with depression score. Conclusion: The prevalence of depression in older people with arthritis is high and was associated with females, the widowed, no formal education; and those with long duration of illness, those using multiple medications, and those with repeated hospitalisation. Contribution: This finding can enhance the suspicion index for depression to establish standard operating procedures, which will help to improve therapeutic practice for caring for the older adult age group.

Fatal Cytomegalovirus Infection in an Adult with Inherited NOS2 Deficiency.

BACKGROUND: Cytomegalovirus (CMV) can cause severe disease in children and adults with a variety of inherited or acquired T-cell immunodeficiencies, who are prone to multiple infections. It can also rarely cause disease in otherwise healthy persons. The pathogenesis of idiopathic CMV disease is unknown. Inbred mice that lack the gene encoding nitric oxide synthase 2 (Nos2) are susceptible to the related murine CMV infection. METHODS: We studied a previously healthy 51-year-old man from Iran who after acute CMV infection had an onset of progressive CMV disease that led to his death 29 months later. We hypothesized that the patient may have had a novel type of inborn error of immunity. Thus, we performed whole-exome sequencing and tested candidate mutant alleles experimentally. RESULTS: We found a homozygous frameshift mutation in NOS2 encoding a truncated NOS2 protein that did not produce nitric oxide, which determined that the patient had autosomal recessive NOS2 deficiency. Moreover, all NOS2 variants that we found in homozygosity in public databases encoded functional proteins, as did all other variants with an allele frequency greater than 0.001. CONCLUSIONS: These findings suggest that inherited NOS2 deficiency was clinically silent in this patient until lethal infection with CMV. Moreover, NOS2 appeared to be redundant for control of other pathogens in this patient. (Funded by the National Center for Advancing Translational Sciences and others.).

Health related quality of life in adults after late repair of tetralogy of fallot: experience from a low-middle income country.

PURPOSE: Without neonatal screening in low middle-income countries like Pakistan, Tetralogy of Fallot (TOF) is a congenital heart disease which frequently remains untreated beyond infancy. The purpose of this study is to determine and assess outcomes and health related quality of life (HRQOL) in patients who undergo complete repair of TOF as adults. METHODS: 56 patients who underwent complete TOF repair after 16 years of age were included. Patient data was collected via retrospective chart review, and a semi structured interview along with Short-Form 36 (SF-36) questionnaire were used to assess HRQOL. RESULTS: 66.1% of patients were male with the mean age at surgery of 22.3 ± 6.00. All patients had a post-operative NYHA Classification of I or II, 94.6% had an ejection fraction of ≥ 50% and 28.6% showed small residual lesions in follow-up echocardiograms. 32.1% of patients suffered post-operative morbidity. For the quantitative assessment using SF-36 scores, patients showed good scores of median 95 (65-100). A major cause of delay to treatment was lack of consensus between treatments offered by doctors in different parts of Pakistan. There was a pattern of 'inability to fit in' among patients who had had late TOF repair, despite self- reported improved HRQOL. CONCLUSION: Our results indicate that even with a delayed diagnosis, surgical repair of TOF produces good functional results. However, these patients face significant psychosocial issues. While early diagnosis remains the ultimate goal, patients undergoing late repair should be managed in more holistic manner with attention to psychological impact of the disease as well.

Inherited IFNAR1 Deficiency in a Child with Both Critical COVID-19 Pneumonia and Multisystem Inflammatory Syndrome.

BACKGROUND: Inborn errors of immunity (IEI) and autoantibodies to type I interferons (IFNs) underlie critical COVID-19 pneumonia in at least 15% of the patients, while the causes of multisystem inflammatory syndrome in children (MIS-C) remain elusive. OBJECTIVES: To detect causal genetic variants in very rare cases with concomitant critical COVID-19 pneumonia and MIS-C. METHODS: Whole exome sequencing was performed, and the impact of candidate gene variants was investigated. Plasma levels of cytokines, specific antibodies against the virus, and autoantibodies against type I IFNs were also measured. RESULTS: We report a 3-year-old child who died on day 56 of SARS-CoV-2 infection with an unusual clinical presentation, combining both critical COVID-19 pneumonia and MIS-C. We identified a large, homozygous loss-of-function deletion in IFNAR1, underlying autosomal recessive IFNAR1 deficiency. CONCLUSIONS: Our findings confirm that impaired type I IFN immunity can underlie critical COVID-19 pneumonia, while suggesting that it can also unexpectedly underlie concomitant MIS-C. Our report further raises the possibility that inherited or acquired dysregulation of type I IFN immunity might contribute to MIS-C in other patients.

Impact of COVID-19 in hematopoietic stem cell transplant recipients: A systematic review and meta-analysis.

BACKGROUND: Hematopoietic stem cell transplant (HSCT) recipients are at increased risk of mortality and morbidity with coronavirus disease 2019 (COVID-19) due to severe immune dysfunction. METHODS: A literature search was performed on PubMed, Cochrane, and Clinical trials.gov from the date of inception to 12/08/2021. We identified 19 original studies reporting data on COVID-19 in HSCT recipients after screening 292 articles. Data were extracted following preferred reporting items for systematic reviews and meta-analysis guidelines. Quality evaluation was done using the National Institutes of Health (NIH) quality assessment tool. Inter-study variance was calculated using Der Simonian-Laird Estimator. Pooled analysis was conducted using MetaXL. A random-effects model was used to estimate the proportions with 95% confidence intervals (CI). RESULTS: Of 6711 patients in 19 studies, 2031 HSCT patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection were analyzed. The median age of patients was 56.9 (range 1-81.6) years, and 63% patients were men according to 14 studies. The median time from transplant to SARS-CoV-2 infection for autologous (auto) and allogeneic (allo) HSCT patients was 23.2 (0.33-350.5) months and 16.4 (0.2-292.7) months, respectively. The median follow-up time after COVID-19 diagnosis was 28 (0-262) days. The COVID-19 mortality rate was 19% (95% CI 0.15-0.24, I2  = 76%, n = 373/2031). The pooled mortality rate was 17% (95% CI 0.12-0.24, I2  = 78%, n = 147/904) in auto-HSCT patients and 21% (95% CI 0.16-0.25, I2  = 60%, n = 231/1103) in allo-HSCT patients. CONCLUSIONS: HSCT recipients have a high risk of mortality and clinical complications due to COVID-19. There is a need for ongoing vigilance, masks, and social distancing, vaccination, and aggressive management of SARS-CoV-2 infection in HSCT recipients.

Rate Coefficients for the Gas-Phase Reactions of Nitrate Radicals with a Series of Furan Compounds.

The atmospheric reaction of a series of furan compounds (furan (F), 2-methylfuran (2-MF), 3-methylfuran (3-MF), 2,5-dimethylfuran (2,5-DMF), and 2,3,5-trimethylfuran (2,3,5-TMF)) with nitrate radical (NO3) has been investigated using the relative rate kinetic method in the CHamber for the Atmospheric Reactivity and the Metrology of the Environment (CHARME) simulation chamber at the laboratoire de Physico-Chimie de l'Atmosphere (LPCA) laboratory (Dunkerque, France). The experiments were performed at (294 ± 2) K atmospheric pressure and under dry conditions (relative humidity, RH < 2%) with proton transfer mass reaction-time of flight-mass spectrometer (PTR-ToF-MS) for the chemical analysis. The following rate coefficients (in units cm3 molecule-1 s-1) were determined: furan, k(F) = (1.51 ± 0.38) × 10-12, 2-methylfuran, k(2-MF) = (1.91 ± 0.32) × 10-11, 3-methylfuran, k(3-MF) = (1.49 ± 0.33) × 10-11, 2,5-dimethylfuran, k(2,5-DMF) = (5.82 ± 1.21) × 10-11, and 2,3,5-trimethylfuran, k(2,3,5-TMF) = (1.66 ± 0.69) × 10-10. The uncertainty on the measured rate coefficient (ΔkFC) includes both the uncertainty on the measurement and that on the rate coefficient of the reference molecule. To our knowledge, this work represents the first determination for the rate coefficient of the 2,3,5-TMF reaction with NO3. This work shows that the reaction between furan and methylated furan compounds with nitrate radical (NO3) is the dominant removal pathway during the night with lifetimes between 0.5 and 55 min for the studied molecules.

mTOR as a Potential Target for the Treatment of Microbial Infections, Inflammatory Bowel Diseases, and Colorectal Cancer.

The mammalian target of rapamycin (mTOR) is the major controller of a number of important cellular activities, including protein synthesis, cell expansion, multiplication, autophagy, lysosomal function, and cellular metabolism. When mTOR interacts with specific adaptor proteins, it forms two complexes, mTOR complex 1 (mTORC1) and mTOR complex 2 (mTORC2). The mTOR signaling system regulates gene transcription and protein manufacturing to control proliferation of cell, differentiation of immune cell, and tumor metabolism. Due to its vital role in case of microbial infections, inflammations and cancer development and progression, mTOR has been considered as a key therapeutic target for the development of targeted medication. As autophagy dysfunction is linked to changes in both innate and adaptive immune responses, bacterial clearance defects, and goblet and Paneth cell malfunction, all of these changes are linked to inflammatory bowel diseases (IBD) and colorectal cancer (CRC) pathogenesis. Preclinical and clinical data have shown that the inhibition and induction of autophagy have significant potential to be translated into the clinical applications. In IBD and several CRC models, mTORC1 inhibitors have been found effective. In the recent years, a number of novel mTOR inhibitors have been investigated in clinical trials, and a number of drugs have shown considerably enhanced efficacy when combined with mTOR inhibitors. The future developments in the mTOR targeting medications can benefit patients in individualized therapy. Advanced and innovative medicines that are more effective and have lower drug resistance are still in high demand. New findings could be relevant in medicine development, pharmacological modification, or future mTOR inhibitor research. Therefore, the goal of this review is to present a comprehensive account of current developments on the mTOR pathway and its inhibitors, with an emphasis on the management of microbial infections, the treatment of inflammatory bowel disease, and the management of colon cancer.

Removal of Malachite Green Dye from Aqueous Solution by Catalytic Wet Oxidation Technique Using Ni/Kaolin as Catalyst.

In this study, natural Algerian kaolin was used as a support and impregnated with nickel at different loading amounts (2 wt.%, 5 wt.%, and 7 wt.%) in order to prepare a supported catalyst. The wet impregnation technique was used in this preparation; nickel oxide (NiO) was the active phase precursor of the catalyst, and the catalysts were designated as follows: 2%, 5%, and 7% Ni/kaolin. These catalysts were put to the test in catalytic wet peroxide oxidation (CWPO) for degrading the organic contaminant malachite green dye (MG). Analytical techniques such as FTIR spectroscopy, X-ray diffraction, BET, and X-fluorescence were used to examine the structure, morphology, and chemical composition of the support and the produced catalysts. Several parameters, including temperature, catalytic dose, metal loading, hydrogen peroxide volume, and kinetic model were systematically investigated. The combination of improved parameters resulted in a significant increase in the catalytic activity, achieving a high removal rate of MG dye of 98.87%.

A Novel STK4 Mutation Impairs T Cell Immunity Through Dysregulation of Cytokine-Induced Adhesion and Chemotaxis Genes.

PURPOSE: Human serine/threonine kinase 4 (STK4) deficiency is a rare, autosomal recessive genetic disorder leading to combined immunodeficiency; however, the extent to which immune signaling and host defense are impaired is unclear. We assessed the functional consequences of a novel, homozygous nonsense STK4 mutation (NM_006282.2:c.871C > T, p.Arg291*) identified in a pediatric patient by comparing his innate and adaptive cell-mediated and humoral immune responses with those of three heterozygous relatives and unrelated controls. METHODS: The genetic etiology was verified by whole genome and Sanger sequencing. STK4 gene and protein expression was measured by quantitative RT-PCR and immunoblotting, respectively. Cellular abnormalities were assessed by high-throughput RT-RCR, RNA-Seq, ELISA, and flow cytometry. Antibody responses were assessed by ELISA and phage immunoprecipitation-sequencing. RESULTS: The patient exhibited partial loss of STK4 expression and complete loss of STK4 function combined with recurrent viral and bacterial infections, notably persistent Epstein-Barr virus viremia and pulmonary tuberculosis. Cellular and molecular analyses revealed abnormal fractions of T cell subsets, plasmacytoid dendritic cells, and NK cells. The transcriptional responses of the patient's whole blood and PBMC samples indicated dysregulated interferon signaling, impaired T cell immunity, and increased T cell apoptosis as well as impaired regulation of cytokine-induced adhesion and leukocyte chemotaxis genes. Nonetheless, the patient had detectable vaccine-specific antibodies and IgG responses to various pathogens, consistent with a normal CD19 + B cell fraction, albeit with a distinctive antibody repertoire, largely driven by herpes virus antigens. CONCLUSION: Patients with STK4 deficiency can exhibit broad impairment of immune function extending beyond lymphoid cells.

Pilot phase experience of the International Quality Improvement Collaborative catheterization registry.

OBJECTIVES: To describe the development of a quality collaborative for congenital cardiac catheterization centers in low and middle-income countries (LMICs) including pilot study data and a novel procedural efficacy measure. BACKGROUND: Absence of congenital cardiac catheterization registries in LMICs led to the development of the International Quality Improvement Collaborative Congenital Heart Disease Catheterization Registry (IQIC-CHDCR). As a foundation for this initiative, the IQIC is a collaboration of pediatric cardiac surgical programs from LMICs. Participation in IQIC has been associated with improved patient outcomes. METHODS: A web-based registry was designed through a collaborative process. A pilot study was conducted from October through December 2017 at seven existing IQIC sites. Demographic, hemodynamic, and adverse event data were obtained and a novel tool to assess procedural efficacy was applied to five specific procedures. Procedural efficacy was categorized using ideal, adequate, and inadequate. RESULTS: A total of 429 cases were entered. Twenty-five adverse events were reported. The five procedures for which procedural efficacy was measured represented 48% of cases (n = 208) and 71% had complete data for analysis (n = 146). Procedure efficacy was ideal most frequently in patent ductus arteriosus (95%) and atrial septal defect (90%) device closure, and inadequate most frequently in coarctation procedures (100%), and aortic and pulmonary valvuloplasties (50%). CONCLUSIONS: The IQIC-CHDCR has designed a feasible collaborative to capture catheterization data in LMICs. The novel tool for procedural efficacy will provide valuable means to identify areas for quality improvement. This pilot study and lessons learned culminated in the full launch of the IQIC-CHDCR.

Use of MASCC score in the inpatient management of febrile neutropenia: a single-center retrospective study.

PURPOSE: The Multinational Association for Supportive Care in Cancer (MASCC) score is used to risk stratify outpatients with febrile neutropenia (FN). However, it is rarely used in hospital settings. We aimed to describe management, use of MASCC score, and outcomes among hospitalized patients with FN. METHODS: We conducted a retrospective cohort study of patients with cancer and FN. We collected patient demographics, cancer characteristics, microbiological profile, MASCC score, utilization of critical care therapies, documentation of goals of care (GOC), and inpatient deaths. Outcomes associated with low- (≥ 21) versus high-risk (< 21) MASCC scores are presented as absolute differences. RESULTS: Of 193 patients, few (2%, n = 3) had MASCC scores documented, but when calculated, 52% (n = 101) had a high-risk score (< 21). GOC were discussed in 12% (n = 24) of patients. Twenty one percent (n = 40) required intermediate/ICU level of care, and 12% (n = 23) died in the hospital. Those with a low-risk score were 33% less likely to require intermediate/ICU care (95% CI 23 to 44%) and 19% less likely to die in the hospital (95% CI 10% to 27%) compared to those with high-risk score. CONCLUSIONS: MASCC score was rarely used for hospitalized patients with FN, but high-risk score was associated with worse outcomes. Education efforts to incorporate MASCC score into the workflow may help identify patients at high risk for complications and help clinicians admit these patients to a higher level of care (e.g., intermediate/ICU care) or guide them to initiate earlier GOC discussions.

Ability of triage nurses to predict, at the time of triage, the eventual disposition of patients attending the emergency department (ED): a systematic literature review and meta-analysis.

INTRODUCTION: Exit block is the most significant cause of poor patient flow and crowding in the emergency department (ED). One proposed strategy to reduce exit block is early admission predictions by triage nurses to allow proactive bed management. We report a systematic review and meta-analysis of the accuracy of nurse prediction of admission at triage. METHODOLOGY: We searched MEDLINE, Cochrane, Embase, CINAHL and grey literature, up to and including February 2019. Our criteria were as follows: prospective studies analysing the accuracy of triage nurse intuition-after gathering standard triage information-for predicting disposition for adult ED patients. We analysed the results of this test-nurse prediction of disposition-in a diagnostic test analysis review style, assessing methodology with the Quality Assessment of Diagnostic Accuracy Studies 2 checklist. We generated sensitivity, specificity and likelihood ratios (LRs). We used LRs and pretest probability of admission (baseline admission rate) to find positive and negative post-test probabilities. RESULTS: We reviewed 10 articles. Of these, seven had meta-analysable data (12 282 participants). The studies varied in participant selection and admission rate, but the majority were of moderate quality and exclusion of each in sensitivity analyses made little difference. Sensitivity was 72% and specificity was 83%. Pretest probability of admission was 29%. Positive and negative post-test probabilities of admission were 63% and 12%, respectively. CONCLUSION: Triage nurse prediction of disposition is not accurate enough to expedite admission for ED patients on a one-to-one basis. Future research should explore the benefit, and best method, of predicting total demand.

A Dispersion Corrected DFT Investigation of the Inclusion Complexation of Dexamethasone with ß-Cyclodextrin and Molecular Docking Study of Its Potential Activity against COVID-19.

The encapsulation mode of dexamethasone (Dex) into the cavity of ß-cyclodextrin (ß-CD), as well as its potential as an inhibitor of the COVID-19 main protease, were investigated using density functional theory with the recent dispersion corrections D4 and molecular docking calculations. Independent gradient model and natural bond orbital approaches allowed for the characterization of the host-guest interactions in the studied systems. Structural and energetic computation results revealed that hydrogen bonds and van der Waals interactions played significant roles in the stabilization of the formed Dex@ß-CD complex. The complexation energy significantly decreased from -179.50 kJ/mol in the gas phase to -74.14 kJ/mol in the aqueous phase. A molecular docking study was performed to investigate the inhibitory activity of dexamethasone against the COVID-19 target protein (PDB ID: 6LU7). The dexamethasone showed potential therapeutic activity as a SARS CoV-2 main protease inhibitor due to its strong binding to the active sites of the protein target, with predicted free energy of binding values of -29.97 and -32.19 kJ/mol as calculated from AutoDock4 and AutoDock Vina, respectively. This study was intended to explore the potential use of the Dex@ß-CD complex in drug delivery to enhance dexamethasone dissolution, thus improving its bioavailability and reducing its side effects.