Outpatient treatment with concomitant vaccine-boosted convalescent plasma for patients with immunosuppression and COVID-19.

Although severe coronavirus disease 2019 (COVID-19) and hospitalization associated with COVID-19 are generally preventable among healthy vaccine recipients, patients with immunosuppression have poor immunogenic responses to COVID-19 vaccines and remain at high risk of infection with SARS-CoV-2 and hospitalization. In addition, monoclonal antibody therapy is limited by the emergence of novel SARS-CoV-2 variants that have serially escaped neutralization. In this context, there is interest in understanding the clinical benefit associated with COVID-19 convalescent plasma collected from persons who have been both naturally infected with SARS-CoV-2 and vaccinated against SARS-CoV-2 ("vax-plasma"). Thus, we report the clinical outcome of 386 immunocompromised outpatients who were diagnosed with COVID-19 and who received contemporary COVID-19-specific therapeutics (standard-of-care group) and a subgroup who also received concomitant treatment with very high titer COVID-19 convalescent plasma (vax-plasma group) with a specific focus on hospitalization rates. The overall hospitalization rate was 2.2% (5 of 225 patients) in the vax-plasma group and 6.2% (10 of 161 patients) in the standard-of-care group, which corresponded to a relative risk reduction of 65% (P = 0.046). Evidence of efficacy in nonvaccinated patients cannot be inferred from these data because 94% (361 of 386 patients) of patients were vaccinated. In vaccinated patients with immunosuppression and COVID-19, the addition of vax-plasma or very high titer COVID-19 convalescent plasma to COVID-19-specific therapies reduced the risk of disease progression leading to hospitalization.IMPORTANCEAs SARS-CoV-2 evolves, new variants of concern (VOCs) have emerged that evade available anti-spike monoclonal antibodies, particularly among immunosuppressed patients. However, high-titer COVID-19 convalescent plasma continues to be effective against VOCs because of its broad-spectrum immunomodulatory properties. Thus, we report clinical outcomes of 386 immunocompromised outpatients who were treated with COVID-19-specific therapeutics and a subgroup also treated with vaccine-boosted convalescent plasma. We found that the administration of vaccine-boosted convalescent plasma was associated with a significantly decreased incidence of hospitalization among immunocompromised COVID-19 outpatients. Our data add to the contemporary data providing evidence to support the clinical utility of high-titer convalescent plasma as antibody replacement therapy in immunocompromised patients.

Corticosteroid Therapy in Acute and Subacute Arachnoiditis - A Case Series.

Arachnoiditis is difficult to treat. Patients are often left frustrated after many failed trials of conservative therapies without symptom resolution. Surgery may provide symptom relief for a short period of time, but their pain often returned. Herein, we present three cases of acute arachnoiditis following three different pain procedures: epidural blood patch, IDDS implant, and epidural steroid injection. The patients were diagnosed and treated with corticosteroids within 10 days of the procedure. Two patients were treated with the same oral steroid regiment, while the third patient was treated with both oral and IV steroid. All three patients had good outcomes at the completion of their steroid therapy. This case series may provide insight into treating acute and subacute arachnoiditis from pain interventions.

Relationship between number of prior lumbar spine surgeries and outcomes following spinal cord stimulator implantation: A multisite, retrospective pooled analysis.

OBJECTIVES: Lumbar spine surgery is a common procedure for treating disabling spine-related pain. In recent decades, both the number and cost of spine surgeries have increased despite technological advances and modification in surgical technique. For those patients that have continued uncontrolled back and/or lower extremity pain following lumbar spine surgery, spinal cord stimulation (SCS) has emerged as a viable treatment option. However, the impact of lumbar spine surgical history remains largely unstudied. Specifically, the current study considers the impact of number of prior lumbar spine surgeries on pain relief outcomes following SCS implantation. MATERIALS AND METHODS: We queried the electronic medical record of five separate pain practices for all patients who have undergone a SCS implant between January 1, 2017, and March 1, 2020. Inclusion criteria consisted of any patients with an SCS implant who underwent a prior lumbar spine surgery. The primary outcome was the mean calculated percentage pain relief in patients based on number of prior lumbar spine surgeries. RESULTS: There was a total of 1974 total SCS implant cases identified across five separate pain clinics. There was no difference in mean calculated pain relief in patients with one prior spine surgery versus those with two or more prior spine surgeries (28.2% vs. 25.8%, adjusted ß-coefficient -3.1, 95% CI -8.9 to 2.7, p = 0.290). Similarly, when analyzing number of spine surgeries as a continuous variable, there was no association between number of spine surgeries and calculated pain relief (adjusted ß-coefficient -1.5, 95% CI -4.0 to 1.1, p = 0.257). Additionally, after patients were stratified based on waveform, there was no association between number of prior lumbar spine surgeries (analyzed both as a categorical and continuous variable) and calculated percentage pain relief. CONCLUSIONS: This multicentered retrospective study found that there was no significant difference in pain scores in individuals who received SCS following one or more lumbar spine surgeries. Additionally, the waveform of the SCS device had no statistically significant impact on post-operative pain scores following one or more lumbar spine surgeries.

A Comprehensive Review of the Genetic and Epigenetic Contributions to the Development of Fibromyalgia.

This narrative review summarizes the current knowledge of the genetic and epigenetic contributions to the development of fibromyalgia (FM). Although there is no single gene that results in the development of FM, this study reveals that certain polymorphisms in genes involved in the catecholaminergic pathway, the serotonergic pathway, pain processing, oxidative stress, and inflammation may influence susceptibility to FM and the severity of its symptoms. Furthermore, epigenetic changes at the DNA level may lead to the development of FM. Likewise, microRNAs may impact the expression of certain proteins that lead to the worsening of FM-associated symptoms.

Greater central airway luminal area in people with COVID-19: a case-control series.

Respiratory epithelium in the conducting airways of the human body is one of the primary targets of SARS-CoV-2 infection, however, there is a paucity of studies describing the association between COVID-19 and physical characteristics of the conducting airways. To better understand the pathophysiology of COVID-19 on the size of larger conducting airways, we determined the luminal area of the central airways in patients with a history of COVID-19 compared to a height-matched cohort of controls using a case-control study design. Using three-dimensional reconstruction from low-dose high-resolution computed tomography, we retrospectively assessed airway luminal cross-sectional area in 114 patients with COVID-19 (66 females, 48 males) and 114 healthy, sex- and height-matched controls (66 females, 48 males). People with a history of smoking, cardiopulmonary disease, or a body mass index greater than 40 kg·m-2 were excluded. Luminal areas of seven conducting airways were analyzed, including trachea, left and right main bronchus, intermediate bronchus, left and right upper lobe, and left lower lobe. For the central conducting airways, luminal area was ~ 15% greater patients with COVID-19 compared to matched controls (p < 0.05). Among patients with COVID-19, there were generally no differences in the luminal areas of the conducting airways between hospitalized patients compared to patients who did not require COVID-19-related hospitalization. Our findings suggest that males and females with COVID-19 have pathologically larger conducting airway luminal areas than healthy, sex- and height-matched controls.

An overview of painful diabetic peripheral neuropathy: Diagnosis and treatment advancements.

Diabetes mellitus remains a public health problem, affecting 422 million people worldwide. Currently, there is no consensus around treating painful diabetic peripheral neuropathy in a step-wise manner. Among the non-pharmacological interventions, neuromodulation has become a promising alternative. Over the past decade, significant clinical trials have paved the way for prompt inclusion of high-frequency spinal cord stimulation within the painful diabetic peripheral neuropathy treatment algorithm. This article aims to provide an updated evidence-based approach for the management of painful diabetic peripheral neuropathy.

Cultural Competency and Surgical Decision Making in Otolaryngology.

Given the high prevalence of otolaryngology infections such as tonsillitis, otitis, and pharyngitis in low and middle income countries, the field of global otolaryngology continues to grow to accommodate patients around the world. This commentary focuses on best practices in transcultural communications between US doctors and foreign patients with an emphasis on cultural competency. We use alternative medicine as an exemplar for how to collaborate with patients to develop treatment plans that respect their cultural beliefs and lifestyles. Rather than assigning value to the patient's alternative medicine practices, we believe that instructing and counseling a patient on how to incorporate follow-up visits and rehabilitation after allopathic medical procedures such as surgical tonsillectomy should be done in a way that respects the patient's preexisting health regimen. By doing so, these new aspects of their health care will take a discrete place in their wellness practices and engender more trust and better health outcomes.

Racial disparities in the cost of inpatient spinal cord stimulator surgery among patients in the 2016-2018 National Inpatient Sample.

INTRODUCTION: Spinal cord stimulation is a promising therapy for patients with treatment refractory pain syndromes, and a viable alternative to chronic opioid therapy. Racial disparities are well-documented in the field of pain medicine. This study seeks to determine whether racial disparities are present in spinal cord stimulator (SCS) surgery involving inpatient hospital stays in the United States. OBJECTIVE: The objective of this study was to analyze the effects of race on health care cost and utilization for patients receiving inpatient SCS surgery. We used total charges incurred by the patient to measure cost and length of stay (LOS) to measures hospital utilization for patients undergoing inpatient SCS surgery. We examined cost and utilization for inpatient surgeries involving SCS insertion, removal, and revision across different race demographics. METHODS: This retrospective cohort study used ICD-10 procedure codes to query for all patients in the 2016-2018 National Inpatient Sample (NIS) who received SCS insertion, removal, and revision surgeries. Univariate analysis was performed in R-studio to assess the relationship between race, LOS, and total charge. Multivariate analysis was also performed in R-studio to adjust for possible confounders. RESULTS: Hispanic race was associated with higher total charge for inpatient SCS surgery (ß=+0.29, p = 3.92e-07). Hospital region was also associated with total charge. The South (ß=+0.12, p = 3.7e-03) and the West (ß=+0.28, p = 3.8e-09) were associated with higher total charge. The linear model also showed that patients with more comorbidities and complex cases paid higher total charges (ß=+0.014, p = 6.2e-04). There was no statistically significant difference in LOS between race demographics. CONCLUSION: After adjusting for age, gender, type of surgical approach (percutaneous vs. open), household income, insurance coverage, hospital region, and hospital location (urban vs. rural vs. teaching), and comorbidity scores, Hispanic patients had higher total charges for inpatient SCS surgery, but there was no disparity in total charge between white and black patients. White patients were older than minority patients at the time of inpatient SCS surgery.

Ga3+ Incorporation into Al13 Keggin Polyoxometalates and the Formation of δ-(GaAl12)7+ and (Ga2.5Al28.5)19+ Polycations.

Keggin-type polyaluminum species (ε-Al13, δ-Al13, Al26, Al30, Al32) can form upon partial hydrolysis of Al3+-bearing solutions and are important species for water purification and contaminant transport. While the structural features for the major Al3+ polyaluminum species have been delineated, much less is known regarding heteroatom substitution and resultant structures other than the previously identified ε-GaAl127+ and ε-GeAl128+ cations. Single-atom substitution within polyaluminum species can change the surface reactivity within water treatment scenarios; thus, it is important to understand heteroatom incorporation within this system. The present work describes the synthesis and characterization of two novel Ga3+-substituted Keggin-type polyaluminum species. Na[GaO4Al12(OH)24(H2O)12](2,6-NDS)4(H2O)20.5 (δ-GaAl12) and [Ga2O8Al28.5Ga0.5(OH)58(H2O)27(SO4)2](SO4)4Cl7(H2O)8.5 (Ga2.5Al28.5) were crystallized from a thermally aged, partially hydrolyzed Ga3+/Al3+ solution. Structural refinement from single-crystal X-ray diffraction indicated fully occupied Ga3+ within tetrahedral site(s) of both isolated species. Partial substitution was observed for octahedral sites for the larger Ga2.5Al28.5 cluster. The chemical compositions of both clusters were confirmed by inductively coupled plasma mass spectrometry (ICP-MS). Density functional theory (DFT) calculations corroborated the structural refinement, with the energetics of Ga3+ substitution suggesting preferential substitution within tetrahedral sites for both species. Additional theoretical work suggests that the rotated trimer in δ-GaAl12 is highly reactive, which can serve as the driving force in the formation of the Ga2.5Al28.5 cluster.