How do I save cell therapy product's storage space?

BACKGROUND: Availability of liquid nitrogen (LN2) freezer storage space is a major challenge for many transplant programs as they continue to grow and accumulate products. The recent trend of allogeneic grafts cryopreservation that started during the COVID-19 pandemic, made the situation even worse requiring an increase in storage capacity. Multi-compartment cryopreservation bags can help save storage space but can be tricky to use. Here, we describe the validation of muti-compartment cryopreservation bags for the purpose of donor lymphocyte infusion (DLI) aliquots. METHODS: We validated the use of five compartment cryobags for cryopreservation of cell therapy products. Four products were cryopreserved using these bags and each compartment was tested post-thaw for product volume distribution, total cell count recovery, and viability. Additionally, the integrity of both bag compartments and labels was assessed as well. RESULTS: All tested specimens met post-thaw viability and TNC recovery acceptability criteria. Fill volume was optimized at 24-25 mL for acceptable volume distribution between aliquots. With proper heat sealing between compartments, all aliquots retain their integrity and cryopreservation labels were adherent and legible. CONCLUSIONS: Muti-compartment bags can be used successfully for cryopreservation of cell therapy products and increase storage capacity.

Validation of automated fluorescent-based technology for measuring total nucleated cell viability of hematopoietic progenitor cell products.

BACKGROUND: A reliable rapid method for measuring total nucleated cell (TNC) viability is essential for cell-based products manufacturing. The trypan blue (TB) exclusion method, commonly used to measure TNC viability of hematopoietic progenitor cell (HPC) products, is a subjective assay, typically uses a microscope, and includes a limited number of cells. The NucleoCounter NC-200 is an automated fluorescent-based cell counter that uses pre-calibrated cartridges with acridine orange and DAPI dyes to measure cell count and viability. This study describes the validation of the NC-200 for testing HPC's viability. METHODS: Samples from 189 fresh and 60 cryopreserved HPC products were included. Fresh products were tested for viability after collection by both TB and NC-200. 7-aminoactinomycin D (7AAD) CD45+ cell viability results were obtained from a flow cytometry test. Cryopreserved products thawed specimens were tested for viability by both TB and NC-200. The NC-200 viability results were compared with the other methods. Acceptability criteria were defined as ≤10% difference between the NC-200 method and the other methods for at least 95% of the samples. RESULTS: Fresh products' mean viability difference between NC-200 and TB or 7AAD CD45+ method was 4.9% (95%CI 4.6-5.4) and 2.8% (95%CI 2.2-3.4), respectively. Thawed products' mean viability difference between NC-200 and TB was 3.0% (95%CI 0.4-5.6). CONCLUSION: The NC-200 automated fluorescent-based method can be used effectively to determine HPC's viability for both fresh and cryopreserved products. It can help eliminate human bias and provide consistent data and operational ease.

North American Study for the Treatment of Recurrent Epistaxis with Doxycycline: The NOSTRIL trial.

BACKGROUND: Hereditary hemorrhagic telangiectasia (HHT) is a vascular bleeding disorder characterized by mucocutaneous telangiectasias and visceral arteriovenous malformations. A frequently debilitating symptom is spontaneous recurrent epistaxis. OBJECTIVE: To evaluate whether doxycycline therapy improves epistaxis in HHT by using a prospective, randomized, placebo-controlled crossover study design. PATIENTS/METHODS: Twenty-two eligible patients between December 2017 and July 2020 at a single center were randomized to one of two study arms: doxycycline treatment followed by placebo, or vice versa. Primary outcomes measured differences in epistaxis severity between treatments. Changes in quality of life, laboratory markers of bleeding, and number of monthly blood transfusions or iron infusions were assessed as secondary endpoints. Additional post hoc endpoints included frequency and duration of dripping epistaxis and gushing epistaxis. A post hoc longitudinal analysis assessed effects of doxycycline over time. RESULTS/CONCLUSIONS: Doxycycline was safe and well tolerated. However, there was no reduction in the three primary outcome measures, nosebleed frequency (p = .16), nosebleed duration (p = .05), and Epistaxis Severity Score (p = .19). Quality of life, hemoglobin level, and number of blood transfusions and iron infusions did not differ between groups. Post hoc analysis demonstrated reduction in instances of gushing (p = .02) with doxycycline, although this finding is of unclear clinical significance. Post hoc longitudinal analysis showed reduction in frequency (mean estimate of coefficient = -0.19, standard error = 0.07, p = .01) and duration (mean estimate of coefficient = -2.33, standard error = 1.08, p = .03) of epistaxis over time. Post hoc findings suggest possible benefit of doxycycline but should be interpreted with caution given the overall negative study. Further investigation is needed with a larger sample size and a longer treatment duration.

Early Radiographic Progression of Scleroderma: Lung Disease Predicts Long-term Mortality.

BACKGROUND: Radiographic end points commonly are included in therapeutic trials for systemic sclerosis (SSc)-interstitial lung disease (ILD); however, the relationship between these outcomes and long-term mortality is unclear. RESEARCH QUESTION: Do short-term changes in radiographic measures of ILD predict long-term survival in patients with SSc? STUDY DESIGN AND METHODS: The Scleroderma Lung Study (SLS) I and II evaluated the safety and efficacy of cyclophosphamide (in SLS I and II) and mycophenolate mofetil (in SLS II) for the treatment of SSc-ILD. Changes in the extent of ILD over time were assessed on high-resolution CT scans of the chest by quantitative image analysis, an approach that applies a computer-based algorithm to assess changes in the radiographic extent of ILD objectively. Participants subsequently were followed for up to 12 years (SLS I) and 8 years (SLS II). Cox proportional hazards models determined whether the change in the quantitative radiographic extent of ILD predicted survival, adjusting for other known predictors of survival. RESULTS: Among SLS I and II participants, 82 and 90 had follow-up imaging scans, respectively, and were included in the analysis. Participants in both trials who showed an increase in the total quantitative radiographic extent of ILD scores of ≥ 2% at 12 months (SLS I) or 24 months (SLS II) experienced significantly worse long-term survival than those with change scores of < 2% (P ≤ .01, log-rank test). In the multivariate Cox models, radiographic progression remained associated with worse long-term survival in SLS I (P = .089) and SLS II (P = .014). INTERPRETATION: Data from two independent clinical trial cohorts with extensive long-term follow-up demonstrated that radiographic progression of ILD over 12 to 24 months, in both treatment and placebo arms, can predict increased risk for long-term mortality in patients with SSc. These findings suggest that radiographic end points may serve as surrogates for mortality in SSc-ILD.

The SAGA and NuA4 component Tra1 regulates Candida albicans drug resistance and pathogenesis.

Candida albicans is the most common cause of death from fungal infections. The emergence of resistant strains reducing the efficacy of first-line therapy with echinocandins, such as caspofungin calls for the identification of alternative therapeutic strategies. Tra1 is an essential component of the SAGA and NuA4 transcriptional co-activator complexes. As a PIKK family member, Tra1 is characterized by a C-terminal phosphoinositide 3-kinase domain. In Saccharomyces cerevisiae, the assembly and function of SAGA and NuA4 are compromised by a Tra1 variant (Tra1Q3) with three arginine residues in the putative ATP-binding cleft changed to glutamine. Whole transcriptome analysis of the S. cerevisiae tra1Q3 strain highlights Tra1's role in global transcription, stress response, and cell wall integrity. As a result, tra1Q3 increases susceptibility to multiple stressors, including caspofungin. Moreover, the same tra1Q3 allele in the pathogenic yeast C. albicans causes similar phenotypes, suggesting that Tra1 broadly mediates the antifungal response across yeast species. Transcriptional profiling in C. albicans identified 68 genes that were differentially expressed when the tra1Q3 strain was treated with caspofungin, as compared to gene expression changes induced by either tra1Q3 or caspofungin alone. Included in this set were genes involved in cell wall maintenance, adhesion, and filamentous growth. Indeed, the tra1Q3 allele reduces filamentation and other pathogenesis traits in C. albicans. Thus, Tra1 emerges as a promising therapeutic target for fungal infections.

Comprehensive genetic analysis of adhesin proteins and their role in virulence of Candida albicans.

Candida albicans is a microbial fungus that exists as a commensal member of the human microbiome and an opportunistic pathogen. Cell surface-associated adhesin proteins play a crucial role in C. albicans' ability to undergo cellular morphogenesis, develop robust biofilms, colonize, and cause infection in a host. However, a comprehensive analysis of the role and relationships between these adhesins has not been explored. We previously established a CRISPR-based platform for efficient generation of single- and double-gene deletions in C. albicans, which was used to construct a library of 144 mutants, comprising 12 unique adhesin genes deleted singly, and every possible combination of double deletions. Here, we exploit this adhesin mutant library to explore the role of adhesin proteins in C. albicans virulence. We perform a comprehensive, high-throughput screen of this library, using Caenorhabditis elegans as a simplified model host system, which identified mutants critical for virulence and significant genetic interactions. We perform follow-up analysis to assess the ability of high- and low-virulence strains to undergo cellular morphogenesis and form biofilms in vitro, as well as to colonize the C. elegans host. We further perform genetic interaction analysis to identify novel significant negative genetic interactions between adhesin mutants, whereby combinatorial perturbation of these genes significantly impairs virulence, more than expected based on virulence of the single mutant constituent strains. Together, this study yields important new insight into the role of adhesins, singly and in combinations, in mediating diverse facets of virulence of this critical fungal pathogen.

A Simple Nematode Infection Model for Studying Candida albicans Pathogenesis.

Candida albicans is an opportunistic fungal pathogen and a model organism to study fungal pathogenesis. It exists as a harmless commensal organism and member of the healthy human microbiome, but can cause life-threatening mucosal and systemic infections. A model host to study C. albicans infection and pathogenesis is the nematode Caenorhabditis elegans. C. elegans is frequently used as a model host to study microbial-host interactions because it can be infected by many human pathogens and there are also close morphological resemblances between the intestinal cells of C. elegans and mammals, where C. albicans infections can occur. This article outlines a detailed methodology for exploiting C. elegans as a host to study C. albicans infection, including a C. elegans egg preparation protocol and an agar-based C. elegans killing protocol to monitor fungal virulence. These protocols can additionally be used to study C. albicans genetic mutants in order to further our understanding of the genes involved in pathogenesis and virulence in C. albicans and the mechanisms of host-microbe interactions. © 2020 Wiley Periodicals LLC. Basic Protocol 1: Preparation of Caenorhabditis elegans eggs Support Protocol 1: Freezing and recovering Caenorhabditis elegans Support Protocol 2: Making superfood agar and OP50 plates Basic Protocol 2: Caenorhabditis elegans/Candida albicans agar killing assay Support Protocol 3: Constructing a worm pick.

Free-breathing Magnetic Resonance Imaging Assessment of Body Composition in Healthy and Overweight Children: An Observational Study.

OBJECTIVE: Conventional, breath-holding magnetic resonance imaging (MRI) assesses body composition by measuring fat volumes and proton density fat fraction (PDFF). However, breath-holding MRI is not always feasible in children. This study's objective was to use free-breathing MRI to quantify visceral and subcutaneous fat volumes and PDFFs and correlate these measurements with hepatic PDFF. METHODS: This was an observational, hypothesis-forming study that enrolled 2 groups of children (ages 6-17 years), healthy children and overweight children with presumed nonalcoholic fatty liver disease. Free-breathing MRI was used to measure visceral and subcutaneous fat volumes and PDFFs, and hepatic PDFF. Imaging biomarkers were compared between groups, and correlations coefficients (r) and coefficients of determination (R) were calculated. RESULTS: When compared with the control group (n = 10), the overweight group (n = 9) had greater mean visceral (1843 vs 329 cm, P < 0.001) and subcutaneous fat volumes (7663 vs 893 cm, P < 0.001), as well as greater visceral (80% vs 45%, p < 0.001) and subcutaneous fat PDFFs (89% vs 75%, P = 0.003). Visceral fat volume (r = 0.79, P < 0.001) and PDFF (r = 0.92, P < 0.001) correlated with hepatic PDFF. In overweight subjects, for each unit increase in visceral fat PDFF, hepatic PDFF increased by 2.64%; visceral fat PDFF explained 54% of hepatic PDFF variation (R = 0.54, P = 0.02). CONCLUSIONS: In this study, we used free-breathing MRI to measure body composition in children. Future studies are needed to investigate the possible value of subcutaneous and visceral fat PDFFs, and validate free-breathing MRI body composition biomarkers.

Technical Note: Design and implementation of a high-throughput pipeline for reconstruction and quantitative analysis of CT image data.

PURPOSE: With recent substantial improvements in modern computing, interest in quantitative imaging with CT has seen a dramatic increase. As a result, the need to both create and analyze large, high-quality datasets of clinical studies has increased as well. At present, no efficient, widely available method exists to accomplish this. The purpose of this technical note is to describe an open-source high-throughput computational pipeline framework for the reconstruction and analysis of diagnostic CT imaging data to conduct large-scale quantitative imaging studies and to accelerate and improve quantitative imaging research. METHODS: The pipeline consists of two, primary "blocks": reconstruction and analysis. Reconstruction is carried out via a graphics processing unit (GPU) queuing framework developed specifically for the pipeline that allows a dataset to be reconstructed using a variety of different parameter configurations such as slice thickness, reconstruction kernel, and simulated acquisition dose. The analysis portion then automatically analyzes the output of the reconstruction using "modules" that can be combined in various ways to conduct different experiments. Acceleration of analysis is achieved using cluster processing. Efficiency and performance of the pipeline are demonstrated using an example 142 subject lung screening cohort reconstructed 36 different ways and analyzed using quantitative emphysema scoring techniques. RESULTS: The pipeline reconstructed and analyzed the 5112 reconstructed datasets in approximately 10 days, a roughly 72× speedup over previous efforts using the scanner for reconstructions. Tightly coupled pipeline quality assurance software ensured proper performance of analysis modules with regard to segmentation and emphysema scoring. CONCLUSIONS: The pipeline greatly reduced the time from experiment conception to quantitative results. The modular design of the pipeline allows the high-throughput framework to be utilized for other future experiments into different quantitative imaging techniques. Future applications of the pipeline being explored are robustness testing of quantitative imaging metrics, data generation for deep learning, and use as a test platform for image-processing techniques to improve clinical quantitative imaging.

Comparison of Double-Freeze versus Modified Triple-Freeze Pulmonary Cryoablation and Hemorrhage Volume Using Different Probe Sizes in an In Vivo Porcine Lung.

PURPOSE: To determine size of ablation zone and pulmonary hemorrhage in double-freeze (DF) vs modified triple-freeze (mTF) cryoablation protocols with different probe sizes in porcine lung. MATERIALS AND METHODS: In 10 healthy adult pigs, 20 pulmonary cryoablations were performed using either a 2.4-mm or a 1.7-mm probe. Either conventional DF or mTF protocol was used. Serial noncontrast CT scans were performed during ablations. Ablation iceball and hemorrhage volumes were measured and compared between protocols and probe sizes. RESULTS: With 1.7-mm probe, greater peak iceball volume was observed with DF compared with mTF, although difference was not statistically significant (16.1 mL ± 1.9 vs 8.8 mL ± 3.6, P = .07). With 2.4-mm probe, DF and mTF produced similar peak iceball volumes (14.0 mL ± 2.8 vs 14.6 mL ± 2.7, P = .88). Midcycle hemorrhage was significantly larger with DF with the 1.7-mm probe (94.3 mL ± 22.2 vs 19.6 mL ± 2.1, P = .02) and with both sizes combined (93.2 mL ± 17.5 vs. 50.9 mL ± 12.6, P = .048). Rate of hemorrhage increase was significantly higher in DF (10.4 mL/min vs 5.1 mL/min, P = .003). End-cycle hemorrhage was visibly larger in DF compared with mTF across probe sizes, although differences were not statistically significant (P = .14 for 1.7 mm probe, P = .18 for 2.4 mm probe, and P = .07 for both probes combined). Rate of increase in hemorrhage during the last thaw period was not statistically different between DF and mTF (3.0 mL/min vs 2.8 mL/min, P = .992). CONCLUSIONS: mTF reduced rate of midcycle hemorrhage compared with DF. With mTF, midcycle hemorrhage was significantly smaller with 1.7-mm probe; although noticeably smaller with 2.4-mm probe, statistical significance was not achieved. Iceball size was not significantly different across both protocols and probe types.

PIKfyve inhibition interferes with phagosome and endosome maturation in macrophages.

Macrophages eliminate pathogens and cell debris through phagocytosis, a process by which particulate matter is engulfed and sequestered into a phagosome. Nascent phagosomes are innocuous organelles resembling the plasma membrane. However, through a maturation process, phagosomes are quickly remodeled by fusion with endosomes and lysosomes to form the phagolysosome. Phagolysosomes are highly acidic and degradative leading to particle decomposition. Phagosome maturation is intimately dependent on the endosomal pathway, during which diverse cargoes are sorted for recycling to the plasma membrane or for degradation in lysosomes. Not surprisingly, various regulators of the endosomal pathway are also required for phagosome maturation, including phosphatidylinositol-3-phosphate, an early endosomal regulator. However, phosphatidylinositol-3-phosphate can be modified by the lipid kinase PIKfyve into phosphatidylinositol-3,5-bisphosphate, which controls late endosome/lysosome functions. The role of phosphatidylinositol-3,5-bisphosphate in macrophages and phagosome maturation remains basically unexplored. Using Fcγ receptor-mediated phagocytosis as a model, we describe our research showing that inhibition of PIKfyve hindered certain steps of phagosome maturation. In particular, PIKfyve antagonists delayed removal of phosphatidylinositol-3-phosphate and reduced acquisition of LAMP1 and cathepsin D, both common lysosomal proteins. Consistent with this, the degradative capacity of phagosomes was reduced but phagosomes appeared to still acidify. We also showed that trafficking to lysosomes and their degradative capacity was reduced by PIKfyve inhibition. Overall, we provide evidence that PIKfyve, likely through phosphatidylinositol-3,5-bisphosphate synthesis, plays a significant role in endolysosomal and phagosome maturation in macrophages.

Thyroglossal duct papillary carcinoma in a 15-year old female and review of pediatric cases of thyroglossal duct carcinoma.

Thyroglossal duct carcinoma is rare, occurring in approximately 1% of thyroglossal duct cysts. Excluding this case report there have been 25 cases of adolescent thyroglossal duct carcinoma reported in the English literature thus far. Most of the pathology reported has been papillary or follicular carcinoma, leading to the question of whether or not to perform concurrent thyroidectomy. Based on our review of the pediatric cases of thyroglossal duct carcinoma we elected not to perform a concurrent thyroidectomy and recommend close follow-up to monitor for signs of future thyroid involvement.

Multi-channel cochlear implant histopathology: are fewer spiral ganglion cells really related to better clinical performance?

CONCLUSION: Our findings show that all cochlear implanted temporal bones had a varied degree of trauma and inflammatory reaction from cochlear implantation. No definitive relationship was observed from our limited number of specimens between residual spiral ganglion cells (SGCs) in implanted temporal bones and clinical speech performance. OBJECTIVES: We hypothesize that there is a relationship between residual SGCs in cochlear implanted temporal bones and clinical speech performance. Our aim was to examine the histopathology of multi-channel cochlear implant temporal bones and to evaluate the relationship of residual SGC counts to clinical hearing performance. METHODS: Temporal bones from four cochlear implant patients were examined histologically. Comparisons were made between implanted and nonimplanted temporal bones. Clinical performance data were obtained from patient charts. RESULTS: There were varying amounts of inflammation in the basal turn of the cochleae in all four implanted temporal bones. Trauma to the facial nerve at the facial recess was noticed in one case. Surviving dendrites varied from 5% to 30% among four cases, with no relationship to clinical performance. The speech recognition scores, measured with Central Institute of the Deaf (CID) sentence score, varied among patients from 4% to 89%, while the patient with the highest SGCs had the best clinical outcome.

An unusual case of a ballpoint pen migrating into the parapharyngeal space and middle mediastinum.

Foreign bodies that penetrate the esophagus and migrate extraluminally are unusual. If they are left untreated, serious complications arise from mediastinitis, and damage to the major structures in the neck can occur. We report a case of a patient who presented with chest pain on inspiration that was found to be caused by a foreign body in the parapharyngeal space and middle mediastinum. Preoperative imaging is critical in obtaining landmarks for safe surgical exploration and is essential to the successful management of penetrating and migrating foreign bodies. This case highlights the importance of localizing the foreign body preoperatively to aid in its surgical removal via a transcervical approach.

A phase I clinical trial of tiopronin, a putative neuroprotective agent, in aneurysmal subarachnoid hemorrhage.

BACKGROUND: The neurotoxic aldehyde 3-aminopropanal (3-AP) contributes to brain injury following cerebral ischemia. Tiopronin (N-2-mercaptopropionyl-glycine[N-2-MPG]) is a US Food and Drug Administration (FDA)-approved drug for the treatment of cystinuria and a putative neuroprotective agent that has been shown to bind and neutralize 3-AP and reduce infarct volumes. OBJECTIVE: The objective of this trial was to establish the safety of tiopronin administration in patients with aneurysmal subarachnoid hemorrhage (aSAH) in preparation for further trials of its efficacy as a neuroprotective agent in this disease process. METHODS: This Phase I dose-escalation trial enrolled three-patient cohorts using a conventional "3+3" study design. Tiopronin dose began at 1 g/d until aSAH Day 14. Each subsequent cohort received a dose of tiopronin based on predetermined guidelines. A maximum dose of 3 g/d was selected, because this is the maximum FDA-approved dose for long-term cystinuria treatment. Subjects were monitored for known side effects of tiopronin. RESULTS: Nine patients were enrolled, the minimum number required based on the study design. None of these patients experienced serious side effects attributable to tiopronin, and no adverse events were noted that could not be attributed to the pathophysiology of aSAH. CONCLUSION: The administration of 3 g/d of tiopronin following aSAH for up to 14 days appears to be safe and without the side effects associated with long-term use. Plans for a randomized, placebo-controlled Phase II trial of tiopronin for neuroprotection following aSAH are underway.

The complement cascade: new avenues in stroke therapy.

Recent evidence has shown that after the initial occlusion, a large portion of stroke patients achieve some degree of reperfusion either through collateral circulation or clot dissolution. However, it appears that this reperfusion may lead to increased inflammation-induced damage. Even though the exact mechanism of this secondary injury is unclear, several experimental studies have indicated an intimate connection between complement and this secondary form of damage. We review the available literature and attempt to identify promising clinical therapeutic targets.

Minimally invasive video-assisted thyroidectomy: a retrospective study over two years of experience.

OBJECTIVE: The minimally invasive video-assisted thyroidectomy technique has slowly gained acceptance. Previous studies have reported advantages of better cosmetic results and faster postoperative recovery. We report preliminary results from our single assistant technique over the initial two years of inception at an academic training center. METHODS: This study consists of a retrospective chart review of 172 cases between May 2005 and September 2007. All cases started as video-assisted thyroidectomy were included. Demographic, pre- and postoperative clinical data, imaging results, and hospital stay were collected. RESULTS: Acceptable data were available for 24 male and 148 female patients who underwent the video-assisted procedure. Five cases were converted to the conventional thyroidectomy. Of the 172 cases, 60 total thyroidectomies and 112 hemithyroidectomies were performed, with 37 cases of malignancy. The average hospitalization was 1.43 days with mean incision length was 3.51 cm, mean surgical time of 91.37 minutes, and mean blood loss of 31 cc. Transient voice problems were noted in 10 patients. CONCLUSION: We found statistically improved operative times, hospital stay, and blood loss the first 2 years with a low rate of temporary complications. It appears that minimally invasive video-assisted thyroidectomy is a safe and feasible option to standard thyroidectomy in selected patients.

Evaluation of a revised Glasgow Coma Score scale in predicting long-term outcome of poor grade aneurysmal subarachnoid hemorrhage patients.

Although many scales attempt to predict outcome following aneurysmal subarachnoid hemorrhage (aSAH), none have achieved universal acceptance, and most scales in common use are not statistically derived. We propose a statistically validated scale for poor grade aSAH patients that combines the Hunt and Hess grades and the Glasgow Coma Scale (GCS) scores; we refer to this as the Poor Grade GCS (PGS). The GCS scores of 160 poor grade aSAH patients (Hunt and Hess Grades 4 and 5) were recorded throughout their hospital stay. Outcomes were assessed by the modified Rankin scale (mRS). Analysis of variance and the Chi-square test were used to guide an analysis of GCS breakpoints according to outcomes. Multivariable logistic regression analysis was used to assess the ability of the Hunt and Hess, GCS, World Federation of Neurological Surgeons Grading Scale, and the PGS to predict long-term outcome. Outcome analysis revealed significant breakpoints in admission GCS scores: PGS-A (GCS 10-12); PGS-B (GCS 8-9); PGS-C (GCS 5-7); PGS-D (GCS 3-4) (p<0.001). In surgical patients, 95.2% of PGS-A, 58.1% of PGS-B, 35.4% of PGS-C, and 28.6% of PGS-D had a favorable one-year outcome. When controlling for age, sex, and operation status, PGS was the only scale predictive of long-term outcome. The odds ratios (OR) for unfavorable outcome according to PGS admission scores (with PGS-A as the reference) were: PGS-B, OR=14.2 (95% CI 1.5-140.5); PGS-C, OR=38.5 (95% CI 4.2-340.0); and PGS-D, OR=63.4 (95% CI 5.6-707.1). In addition to PGS admission scores, an age of 70 or greater was a significant predictor of poor outcome with an OR of 7.5 (95% CI 1.8-30.7). No patients with a PGS-C or PGS-D over the age of 70 had a favorable long-term outcome. Therefore, elements of the Hunt and Hess and GCS can be combined into the PGS to predict long-term outcome in poor grade aSAH patients. However, patients with PGS-C and PGS-D over the age of 70 should be assessed carefully prior to definitive treatment.