Extrafollicular B cell responses correlate with neutralizing antibodies and morbidity in COVID-19.

A wide spectrum of clinical manifestations has become a hallmark of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) COVID-19 pandemic, although the immunological underpinnings of diverse disease outcomes remain to be defined. We performed detailed characterization of B cell responses through high-dimensional flow cytometry to reveal substantial heterogeneity in both effector and immature populations. More notably, critically ill patients displayed hallmarks of extrafollicular B cell activation and shared B cell repertoire features previously described in autoimmune settings. Extrafollicular activation correlated strongly with large antibody-secreting cell expansion and early production of high concentrations of SARS-CoV-2-specific neutralizing antibodies. Yet, these patients had severe disease with elevated inflammatory biomarkers, multiorgan failure and death. Overall, these findings strongly suggest a pathogenic role for immune activation in subsets of patients with COVID-19. Our study provides further evidence that targeted immunomodulatory therapy may be beneficial in specific patient subpopulations and can be informed by careful immune profiling.

Genetic diversity, population structure and origin of the native goats in Central Laos.

Maintaining genetic diversity and variation in livestock populations is critical for natural and artificial selection promoting genetic improvement while avoiding problems due to inbreeding. In Laos, there are concerns that there has been a decline in genetic diversity and a rise in inbreeding among native goats in their village-based smallholder system. In this study, we investigated the genetic diversity of Lao native goats in Phin, Songkhone and Sepon districts in Central Laos for the first time using Illumina's Goat SNP50 BeadChip. We also explored the genetic relationships between Lao goats with 163 global goat populations from 36 countries. Our results revealled a close genetic relationship between Lao native goats and Chinese, Mongolian and Pakistani goats, sharing ancestries with Guangfen, Jining Grey and Luoping Yellow breeds (China) and Teddi goats (Pakistan). The observed (Ho) and expected (He) heterozygosity were 0.292 and 0.303 (Laos), 0.288 and 0.288 (Sepon), 0.299 and 0.308 (Phin) and 0.289 and 0.305 (Songkhone), respectively. There was low to moderate genetic differentiation (FST: 0.011-0.043) and negligible inbreeding coefficients (FIS: -0.001 to 0.052) between goat districts. The runs of homozygosity (ROH) had an average length of 5.92-6.85 Mb, with short ROH segments (1-5 Mb length) being the most prevalent (66.34%). Longer ROH segments (20-40 and >40 Mb length categories) were less common, comprising only 4.81% and 1.01%, respectively. Lao goats exhibit moderate genetic diversity, low-inbreeding levels and adequate effective population size. Some genetic distinctions between Lao goats may be explained by geographic and cultural features.

Detection of Newly Secreted Antibodies Predicts Nonrecurrence in Primary Clostridioides difficile Infection.

Within 8 weeks of primary Clostridioides difficile infection (CDI), as many as 30% of patients develop recurrent disease with the associated risks of multiple relapses, morbidity, and economic burden. There are no clear clinical correlates or validated biomarkers that can predict recurrence during primary infection. This study demonstrated the potential of a simple test for identifying hospitalized CDI patients at low risk for disease recurrence. Forty-six hospitalized CDI patients were enrolled at Emory University Hospitals. Samples of serum and a novel matrix from circulating plasmablasts called "medium-enriched for newly synthesized antibodies" (MENSA) were collected during weeks 1, 2, and 4. Antibodies specific for 10 C. difficile antigens were measured in each sample. Among the 46 C. difficile-infected patients, 9 (19.5%) experienced recurrence within 8 weeks of primary infection. Among the 37 nonrecurrent patients, 23 (62%; 23/37) had anti-C. difficile MENSA antibodies specific for any of the three toxin antigens: TcdB-CROP, TcdBvir-CROP, and/or CDTb. Positive MENSA responses occurred early (within the first 12 days post-symptom onset), including six patients who never seroconverted. A similar trend was observed in serum responses, but they peaked later and identified fewer patients (51%; 19/37). In contrast, none (0%; 0/9) of the patients who subsequently recurred after hospitalization produced antibodies specific for any of the three C. difficile toxin antigens. Thus, patients with a negative early MENSA response against all three C. difficile toxin antigens had a 19-fold greater relative risk of recurrence. MENSA and serum levels of immunoglobulin A (IgA) and/or IgG antibodies for three C. difficile toxins have prognostic potential. These immunoassays measure nascent immune responses that reduce the likelihood of recurrence thereby providing a biomarker of protection from recurrent CDI. Patients who are positive by this immunoassay are unlikely to suffer a recurrence. Early identification of patients at risk for recurrence by negative MENSA creates opportunities for targeted prophylactic strategies that can reduce the incidence, cost, and morbidity due to recurrent CDI.

Sphenopalatine Ganglion Block for Postdural Puncture Headaches in a Thrombocytopenic Adolescent Young Adult: A Case Report.

The epidural blood patch is the gold-standard therapy to treat postdural puncture headaches from dural puncture when conservative therapies fail. However, an epidural blood patch is contraindicated in patients with coagulopathy and thrombocytopenia (platelet count of 60,000/µL) due to concerns of an epidural hematoma. We present a case of an adolescent with acute lymphocytic leukemia, thrombocytopenia, and persistent postdural puncture headaches. The patient was successfully treated with a sphenopalatine ganglion nerve block at the bedside without any side effects and complications.

Application of the fulcrum axis to estimate the central scapular axis.

BACKGROUND: Glenoid resurfacing can be a challenging component of total shoulder arthroplasty when significant glenoid retroversion or deformity is present. The purpose of this study was to determine whether a newly designed glenoid-targeting guide using the parallel relationship between glenoid version and an anatomic fulcrum axis could accurately estimate the central axis of the scapula. MATERIALS AND METHODS: Three orthopaedic surgeons used a newly designed glenoid-targeting guide to place a guide pin into 6 normal Sawbones scapulae (Pacific Research Laboratories, Vashon Island, WA, USA), 6 retroverted Sawbones scapulae, 8 cadaveric scapular specimens, and 5 cadaveric shoulder specimens. Angles of deviation from the central scapular axis and from perpendicular to the fulcrum axis were measured. RESULTS: The mean pin deviation angle from the central scapular axis and the mean fulcrum deviation angle for the normal Sawbones scapulae were 1.7° (SD, 1.2°) and 2.1° (SD, 1.5°), respectively. For altered retroverted Sawbones scapulae, the mean deviation angles were 1.8° (SD, 1.2°) and 2.8° (SD, 1.6°), respectively. The combined mean pin deviation angle and mean fulcrum deviation angle for cadaveric shoulder specimens were 2.8° (SD, 3.3°) and 2.3° (SD, 2.3°), respectively. The surgeons' results did not differ significantly whether using Sawbones models, cadaveric scapular specimens, or cadaveric shoulder specimens. CONCLUSION: A glenoid-targeting guide based on the relationship of the fulcrum axis and glenoid version can be used to accurately estimate the central scapular axis. Such a tool can be accurate and reliable intraoperatively, aiding in glenoid component placement to within 5° of ideal version, irrespective of glenoid deformity.

Congenital Myasthenic Syndrome With Malignant Hyperthermia Susceptibility in a Child Undergoing Adenotonsillectomy for Obstructive Sleep Apnea: A Case Report.

Congenital myasthenic syndromes are rare genetic diseases involving pathologic proteins in the neuromuscular junction. Malignant hyperthermia susceptibility is a genetic disorder involving a hypermetabolic response to volatile anesthetics and depolarizing neuromuscular blocking agents. We present the first reported case of a 3-year-old boy with both congenital myasthenic syndrome and malignant hyperthermia susceptibility, resulting from a mutation in the ryanodine receptor type 1 gene, who underwent an adenotonsillectomy for severe obstructive sleep apnea. We discuss the anesthetic challenges in navigating these 3 comorbidities in the setting of airway surgery.

Comparable analysis of outcomes for allogeneic peripheral blood stem cell transplantation from matched related and matched unrelated donors in acute myeloid leukemia.

This study compared the results of allogeneic peripheral blood stem cell transplantation (PBSCT) from unrelated and related donors in 142 consecutive patients with acute myeloid leukemia (AML). The cumulative incidence of acute graft-versus-host disease (GVHD) was 37.6% in the related PBSCT group and 53.7% in the unrelated PBSCT group. The cumulative incidence of extensive chronic GVHD was also higher in the unrelated PBSCT group (19.5%) than in the related PBSCT group (8.9%). The overall survival rate at 4 years was 62.4 ± 5.4 and 53.8 ± 1.2% (p = 0.535) in the related and unrelated PBSCT group, respectively. In a multivariate analysis, unrelated PBSCT was identified as a risk factor for the development of extensive chronic GVHD (hazard ratio = 3.019, p = 0.027). Unfavorable cytogenetics and the disease status at the time of transplantation were found to be related to overall survival. In the case of high-risk AML, the survival rate and relapse incidence were significantly better in the matched unrelated PBSCT group (p = 0.047 and 0.039, respectively). In conclusion, the allogeneic PBSCT outcomes for AML were comparable in the matched related and matched unrelated groups. Nonetheless, for high-risk AML patients, matched unrelated PBSCT was found to be preferable to matched related PBSCT.

Use of point-of-care ultrasound in the diagnosis and treatment of pulmonary oedema in an infant.

This case demonstrates the value of perioperative point-of-care ultrasound for rapid bedside evaluation and treatment of pulmonary oedema in an infant. A nine-week-old male infant undergoing cleft lip repair received significant intravenous fluid resuscitation for intraoperative hypotension. After uneventful extubation, he developed increased work of breathing and a gradual decline in oxygen saturation despite supplemental oxygen by way of a facemask. Lung point-of-care ultrasound revealed confluent B-lines in multiple lung fields, consistent with pulmonary oedema, likely from fluid overload. He was treated with furosemide resulting in clinical improvement within 30 minutes.

Hyaluronic acid injections for treatment of pediatric sickle cell avascular necrosis of the humeral head.

BACKGROUND: Avascular necrosis (AVN) can impact up to 50% of patients with sickle cell disease (SCD) and can result in significant pain, decline in physical function and decreased quality of life. While hyaluronic acid (HA) has been used in the adult population for shoulder osteoarthritic pain, we present the first published pediatric case of HA injections in the glenohumeral joint, used to improve function and pain control. CASE PRESENTATION: The patient is a 12-year-old woman with SCD, who suffered from chronic pain due to AVN of the humeral and femoral head. Despite engaging in a multidisciplinary pain management plan, she continued to have severe decline in physical functioning and became a wheelchair user. As a result, she was scheduled for a right total hip arthroplasty, which necessitated aggressive postoperative therapies using the glenohumeral joint. To improve this pain and to facilitate postoperative recovery, the patient underwent 4 weekly HA injections into the glenohumeral joint. Over a 2-month period, the patient was able to improve physical functioning, decrease opiate use and participate in all postoperative therapies. CONCLUSION: Conservative options to improve functioning and pain are especially important in pediatric patients where it may be desirable to delay surgical interventions until skeletal maturity. Our case report demonstrates the benefits of intra-articular HA as part of a multidisciplinary pain management plan to improve function and decrease pain related to AVN of the humeral head. Future studies should assess the long-term benefits of HA injections for AVN in the setting of SCD.

Microtia Reconstruction and Erector Spinae Block in Children: A Case Series With Chart Review.

OBJECTIVES: Autologous reconstruction of microtia is advantageous due to its inherent biocompatibility and long-term stability, but postoperative pain associated with costal harvest is a significant issue. A well-planned pain management approach is imperative. Our objective is to introduce the novel application of erector spinae block anesthesia in pediatric microtia reconstruction and evaluate its impact on pain scores, use of opioids, and hospital length of stay. STUDY DESIGN: Case series with chart review. SETTING: Patients undergoing stage 1 microtia reconstruction at a tertiary pediatric hospital. METHODS: Data collected included demographics, opioid amounts, Wong-Baker FACES Pain Rating Scale scores, opioid-related side effects, and hospital length of stay. We used generalized estimating equations to examine the effect of erector spinae block use on total opioid use and pain scores and a linear regression model to assess the effect on hospital stay. RESULTS: Forty-seven patients were included: 14 in the erector spinae block group and 33 in the continuous wound pump group. The mean age was 8.3 years (SD, 2; range, 6-13), and 13 (32%) were female. Patients in the erector spinae block group had a 65.44% decrease in adjusted total opioid use (95% CI, -79.72% to -41.10%; P < .0001), a decrease in length of hospital stay (ß = -1.69 [95% CI, -2.11 to -1.26], P < .0001), and no difference in reported pain scores when compared with patients in the continuous wound pump group. CONCLUSIONS: This study demonstrates that early experience with an erector spinae block resulted in decreased opioid use and shorter hospital stay as compared with continuous wound infiltration with local anesthetic.

Epidural blood patch to treat a postsurgical cerebrospinal fluid leak using central line kit.

Epidural blood patches are considered definitive treatment for postdural puncture headache in adult patients. However, they are infrequently used in children or in patients with altered spine anatomy. In patients who have undergone recent spine surgery, the lumbar epidural space can be approached safely via the caudal canal. Our case demonstrates a novel technique to perform an epidural blood patch from a caudal approach using a commonly available central line kit for a 15-year-old patient with severe spinal headache due to cerebrospinal fluid leak following a hemilaminectomy.

Lay abstract An epidural blood patch is an injection of the patient's own blood into their back in the epidural space, which is the definitive treatment for headaches as a result of spinal fluid leakage. However, they are infrequently used and difficult to perform in children or in patients who have had prior back surgeries. In patients who have undergone recent spine surgery, their back-epidural space can be approached safely through caudal canal near the tailbone. Our case demonstrates a novel technique to perform an epidural blood patch from a caudal approach using a commonly available central line kit in a 15-year-old patient with severe spinal headache due to cerebrospinal fluid leak after a back surgery.

Urgent surgery for COVID-19-positive pediatric patient.

BACKGROUND: We present a case of COVID-19-positive pediatric patient for urgent urological surgery by spinal anesthesia to avoid aerosolizing procedure. CASE PRESENTATION: A 12-year-old, COVID-19-positive boy presented for urgent wound incision and drainage at the circumcision site. Our anesthetic plan consisted of spinal anesthesia with sedation. He was transported from the COVID-19 isolation floor to the negative pressure operating room. He was placed in lateral decubitus position and oxygen was delivered through facemask. Under sedation, spinal anesthesia was achieved at first attempt. The patient maintained spontaneous ventilation without airway intervention. Patient was recovered in the operation room then transported back to the floor. CONCLUSION: Spinal anesthesia is a safe alternative to general endotracheal anesthesia for many pediatric urology procedures. Effective team communication and preparation are keys when caring COVID-19-positive patient in perioperative setting to avoid minimize the risk to healthcare providers.

Effectiveness of liposomal bupivacaine in adductor canal blocks for pediatric knee procedures: A case series.

Adductor canal block (ACB) using liposomal bupivacaine (LB) has been shown to be effective in achieving prolonged postoperative pain control for knee procedures in adults. However, published literature on the use of ACB with LB in pediatric patients continues to be lacking. We present a case series on the effectiveness of ACB using LB in achieving extended postoperative pain control for pediatric patients undergoing knee surgeries. Our patients reported at least 96 h of pain relief with zero postoperative opioid requirements and no major adverse reactions from LB.

Novel immunoassay for diagnosis of ongoing Clostridioides difficile infections using serum and medium enriched for newly synthesized antibodies (MENSA).

BACKGROUND: Clostridioides difficile infections (CDI) have been a challenging and increasingly serious concern in recent years. While early and accurate diagnosis is crucial, available assays have frustrating limitations. OBJECTIVE: Develop a simple, blood-based immunoassay to accurately diagnose patients suffering from active CDI. MATERIALS AND METHODS: Uninfected controls (N = 95) and CDI patients (N = 167) were recruited from Atlanta area hospitals. Blood samples were collected from patients within twelve days of a positive CDI test and processed to yield serum and PBMCs cultured to yield medium enriched for newly synthesized antibodies (MENSA). Multiplex immunoassays measured Ig responses to ten recombinant C. difficile antigens. RESULTS: Sixty-six percent of CDI patients produced measurable responses to C. difficile antigens in their serum or MENSA within twelve days of a positive CDI test. Fifty-two of the 167 CDI patients (31%) were detectable in both serum and MENSA, but 32/167 (19%) were detectable only in MENSA, and 27/167 (16%) were detectable only in serum. DISCUSSION: We describe the results of a multiplex immunoassay for the diagnosis of ongoing CDI in hospitalized patients. Our assay resolved patients into four categories: MENSA-positive only, serum-positive only, MENSA- and serum-positive, and MENSA- and serum-negative. The 30% of patients who were MENSA-positive only may be accounted for by nascent antibody secretion prior to seroconversion. Conversely, the serum-positive only subset may have been more advanced in their disease course. Immunocompromise and misdiagnosis may have contributed to the 34% of CDI patients who were not identified using MENSA or serum immunoassays. IMPORTANCE: While there was considerable overlap between patients identified through MENSA and serum, each method detected a distinctive patient group. The combined use of both MENSA and serum to detect CDI patients resulted in the greatest identification of CDI patients. Together, longitudinal analysis of MENSA and serum will provide a more accurate evaluation of successful host humoral immune responses in CDI patients.

One-Stop Serum Assay Identifies COVID-19 Disease Severity and Vaccination Responses.

SARS-CoV-2 has caused over 100,000,000 cases and almost 2,500,000 deaths globally. Comprehensive assessment of the multifaceted antiviral Ab response is critical for diagnosis, differentiation of severity, and characterization of long-term immunity, especially as COVID-19 vaccines become available. Severe disease is associated with early, massive plasmablast responses. We developed a multiplex immunoassay from serum/plasma of acutely infected and convalescent COVID-19 patients and prepandemic and postpandemic healthy adults. We measured IgA, IgG, and/or IgM against SARS-CoV-2 nucleocapsid (N), spike domain 1 (S1), S1-receptor binding domain (RBD) and S1-N-terminal domain. For diagnosis, the combined [IgA + IgG + IgM] or IgG levels measured for N, S1, and S1-RBD yielded area under the curve values ≥0.90. Virus-specific Ig levels were higher in patients with severe/critical compared with mild/moderate infections. A strong prozone effect was observed in sera from severe/critical patients-a possible source of underestimated Ab concentrations in previous studies. Mild/moderate patients displayed a slower rise and lower peak in anti-N and anti-S1 IgG levels compared with severe/critical patients, but anti-RBD IgG and neutralization responses reached similar levels at 2-4 mo after symptom onset. Measurement of the Ab responses in sera from 18 COVID-19-vaccinated patients revealed specific responses for the S1-RBD Ag and none against the N protein. This highly sensitive, SARS-CoV-2-specific, multiplex immunoassay measures the magnitude, complexity, and kinetics of the Ab response and can distinguish serum Ab responses from natural SARS-CoV-2 infections (mild or severe) and mRNA COVID-19 vaccines.

Continuous Intravenous Lidocaine Provides Effective Pain Control in a Palliative Child: A Case Report.

Lidocaine infusion is often used as part of a perioperative, multimodal pain management plan. We present its use to treat an 8-year-old child with devastating headaches. His symptoms stemmed from an inoperable supratentorial ependymoma that was causing thalamic bleeding and increased intracranial pressure. Many commonly used pain medications are associated with deleterious side effects such as bleeding and excessive sedation. These effects prevent lucidity for interactions, confound neurologic examination. A lidocaine infusion resulted in significant pain relief without these negative side effects. We discuss lidocaine infusion use and considerations for children suffering from intractable headaches.

Engaging Parents in Analgesia Selection and Racial/Ethnic Differences in Analgesia Given to Pediatric Patients Undergoing Urologic Surgery.

BACKGROUND: Family-centered care aims to consider family preferences and values in care delivery. Our study examines parent decisions regarding anesthesia type (caudal regional block or local anesthesia) among a diverse sample of children undergoing urologic surgeries. Differences in anesthesia type were examined by known predictors of health disparities, including child race/ethnicity, parental English proficiency, and a proxy for household income. METHODS: A retrospective review of 4739 patients (including 25.4% non-Latino/a White, 8.7% non- Latino/a Asians, 7.3% non-Latino/a Black, 23.1% Latino/a, and 35.4% others) undergoing urologic surgeries from 2016 to 2020 using univariate and logistic regression analyses. RESULTS: 62.1% of Latino/a parents and 60.8% of non-Latino/a Black parents did not agree to a regional block. 65.1% of Spanish-speaking parents with limited English Proficiency did not agree to a regional block. Of parents from households below poverty lines, 61.7% did not agree to a caudal regional block. In regression analysis, Latino/a and non- Latino/a Black youth were less likely to receive caudal regional block than non- Latino/a White patients. CONCLUSIONS: We found disparities in the use of pediatric pain management techniques. Understanding mechanisms underlying Latino/a and non- Latino/a Black parental preferences may help providers reduce these disparities.