Report on 4 cases with decreased recovery due to neutralizing antibodies specific for PEGylated recombinant factor VIII.

BACKGROUND: The immunogenicity, safety, and efficacy of recombinant factor VIII (rFVIII) have gained increasing interest after the introduction of extended half-life products with various modifications of the rFVIII molecule, such as covalent attachment of polyethylene glycol (PEG). Anti-PEG antibodies may be associated with a temporary reduction of FVIII recovery, but according to previous studies, they usually disappear after continuous dosing. Anti-PEG antibodies with an inhibitory capacity have never been demonstrated in patients treated with PEGylated rFVIII products. OBJECTIVES: To routinely switch from standard half-life to PEGylated extended half-life rFVIII products in patients with hemophilia A. METHODS: From December 2022 until May 2023, 83 adults with hemophilia A attending Oslo Haemophilia Comprehensive Care Centre received a test dose with a PEGylated rFVIII product to switch treatment. Four patients presented with decreased recovery without the presence of an FVIII inhibitor. Accordingly, we performed a variant inhibitor test utilizing different rFVIII concentrates as a source of FVIII and enzyme-linked immunosorbent assay to search for anti-PEG antibodies. RESULTS: We found inhibitory anti-PEG/anti-PEGylated rFVIII antibodies in 4 patients (5%), both persistent and transient, explaining the impaired recovery. The patients had neutralizing anti-PEG antibodies prior to the first dosing of PEGylated rFVIII. We demonstrated neutralizing antibodies (mainly immunoglobuline G) specific for PEG and all 3 commercially available PEGylated rFVIII products. CONCLUSION: The number of patients with inhibitory anti-PEG antibodies was significant, and the presence of inhibitors against PEGylated rFVIII emphasizes the importance of individual monitoring when switching FVIII concentrates to ensure safety and efficacy of the treatment.

A Safe Anti-A2 Titer for a Successful A2 Incompatible Kidney Transplantation: A Single-center Experience and Review of the Literature.

BACKGROUND: Kidney allocation system allows blood type B candidates accept kidneys from A2/A2B donors. There is no mandate by UNOS on which the anti-A2 level is acceptable. We aimed to investigate the safety of kidney transplant in blood group B patients with anti-A2 titers ≤16. METHODS: We performed 41 A2-incompatible kidney transplants in blood group B recipients between May 2015 and September 2019. Clinical outcomes were compared with a control group of 75 blood group B recipients who received blood group compatible kidney transplantation at the same period. RESULTS: Of the 41 recipients, 85% were male, 48% African American, with a median age of 53 (20-73) y. Thirty-eight (93%) were deceased-donor and 3 (7%) were living-donor kidney transplant recipients. Pretransplant anti-A2 IgG titers were 2 in 16, 4 in 9, 8 in 6, and 16 in 5 and too weak to titer in 5 recipients. Eight patients had pretransplant donor-specific antibodies. During a median follow-up of 32.6 mo (6-57.3) patient and graft survival were 100% and 92% in the A2-incompatible kidney transplant group, and 91% and 92% in the blood group compatible group, respectively. Twelve A2-incompatible recipients underwent a 21 clinically indicated kidney biopsies at a median 28 d (6-390) after transplantation. None of the patients developed acute antibody-mediated rejection and 2 patients (5%) had acute T-cell-mediated rejection. Interestingly, peritubular capillary C4d positivity was seen in 7 biopsies which did not have any findings of acute rejection or microvascular inflammation but not in any of the rejection-free biopsies in the control group. C4d positivity was persistent in 5 of those patients who had follow-up biopsies. CONCLUSIONS: A2-incompatible transplantation is safe in patients with anti-A2 titers ≤16 with excellent short-term kidney allograft outcomes. C4d positivity is frequent in allograft biopsies without acute rejection.

Commercial insurance delays direct-acting antiviral treatment for hepatitis C kidney transplantation into uninfected recipients.

INTRODUCTION: The advent of direct-acting antivirals (DAAs) has created an avenue for transplantation of hepatitis C virus (HCV)-infected donors into uninfected recipients (D+/R-). The donor transmission of HCV is then countered by DAA administration during the post-operative period. However, initiation of DAA treatment is ultimately dictated by insurance companies. METHODS: A retrospective chart review of 52 D+/R- kidney recipients who underwent DAA treatment post-transplant was performed. Patients were grouped according to their prescription coverage plans, managed by either commercial or government pharmacy benefit managers (PBMs). RESULTS: Thirty-nine patients had government PBMs and 13 had commercial PBMs. Demographics were similar between the two groups. All patients developed HCV viremia, but cleared the virus after treatment with DAA. Patients with government PBMs were treated earlier compared to those with commercial PBMs (11 days vs 26 days, P = .01). Longer time to DAA initiation resulted in higher peak viral loads (ß = 0.39, R2  = .15, P = .01) and longer time to HCV viral load clearance (ß = 0.41, R2  = .17, P = .01). CONCLUSIONS: D+/R- transplantation offers patients an alternative strategy to increase access. However, treatment can be profoundly delayed by a third-party payer authorization process that may be subjecting patients to unnecessary risks and worsened outcomes.

COVID-19 infection in kidney transplant recipients at the epicenter of pandemics.

We investigated the prevalence and clinical outcomes of COVID-19 in recipients of kidney transplants in the Bronx, New York, one of the epicenters of the pandemic. Between March 16 and June 2, 2020, 132 kidney transplant recipients tested positive by SARS-CoV-2 RT-PCR. From May 3 to July 29, 2020, 912 kidney transplant recipients were screened for SARS-CoV-2 IgG antibodies during routine clinic visits, of which 16.6% tested positive. Fifty-five of the 152 patients had previously tested positive by RT-PCR, while the remaining 97 did not have significant symptoms and had not been previously tested by RT-PCR. The prevalence of SARS-CoV-2 infection was 23.4% in the 975 patients tested by either RT-PCR or SARS-CoV-2 IgG. Older patients and patients with higher serum creatinine levels were more likely diagnosed by RT-PCR compared to SARS-CoV-2 IgG. Sixty-nine RT-PCR positive patients were screened for SARS-CoV-2 IgG antibodies at a median of 44 days post-diagnosis (Inter Quartile Range 31-58) and 80% were positive. Overall mortality was 20.5% but significantly higher (37.8%) in the patients who required hospitalization. Twenty-three percent of the hospitalized patients required kidney replacement therapy and 6.3% lost their allografts. In multivariable analysis, older age, receipt of deceased-donor transplantation, lack of influenza vaccination in the previous year and higher serum interleukine-6 levels were associated with mortality. Thus, 42% of patients with a kidney transplant and with COVID-19 were diagnosed on antibody testing without significant clinical symptoms; 80% of patients with positive RT-PCR developed SARS-CoV-2 IgG and mortality was high among patients requiring hospitalization.

Use of epinephrine in emergency department depends on anaphylaxis severity in children.

Despite multiple recommendations, intramuscular epinephrine is poorly prescribed in emergency department receiving pediatric anaphylaxis. To evaluate the role of severity symptoms on this use, we included all admissions for a diagnosis linked to possible allergy in the two pediatric emergency departments of our institution between January 2010 and December 2015. Selection and analysis were restricted to children under 18 years fulfilling Sampson's criteria for anaphylaxis. We retrospectively ranked these admissions with the Ring and Messmer anaphylaxis severity score and compared the use of epinephrine according to this classification. Among 422,483 admissions, 204 (0.05%) fulfilled the anaphylaxis criteria (170 (83.3%) grade II anaphylaxis, and 34 (16.7%) grade III; mean age 7.9 years). Previous allergy, anaphylaxis, and asthma were found in respectively 60.8%, 36.8%, and 35.1%. Food allergy was the main suspected causal trigger. Epinephrine was used in 32.7% (n = 65/199), before admission (11.4% (n = 23/201)) or in the emergency department (22.2% (n = 45/202)). Epinephrine was more frequently prescribed in grade III than in grade II anaphylaxis (84.8% vs 22.3%, p < 0.001; OR = 19.05 [7.05-54.10]). Upon discharge, epinephrine auto-injectors prescription and allergy referral were rare (31.7% and 44.2%).Conclusion: Pediatricians intuitively adapt their epinephrine use to the severity of the anaphylaxis and contribute to epinephrine underuse in pediatric anaphylaxis. What is known: • Intramuscular epinephrine is the recommended treatment for pediatric anaphylaxis. However, most of the European and North-American studies show a low prescription rate of epinephrine in both prehospital and pediatric emergency department management. • Reasons for such a low prescription rate are unknown. What is new: • This study confirms that intramuscular epinephrine is poorly prescribed in pediatric anaphylaxis (about one case among 10 before admission and one among 5 in pediatric emergency departments). • Despite recommendations, pediatricians intuitively adapt their prescription to the clinical severity of anaphylaxis, with a fourfold increase prescription in grade III compared to grade II anaphylaxis. This medical behavior ascertainment may be in part explained by the delay between the ED admission/management and the anaphylactic episode onset.

RADIX: rhizoslide platform allowing high throughput digital image analysis of root system expansion.

BACKGROUND: Phenotyping of genotype-by-environment interactions in the root-zone is of major importance for crop improvement as the spatial distribution of a plant's root system is crucial for a plant to access water and nutrient resources of the soil. However, so far it is unclear to what extent genetic variations in root system responses to spatially varying soil resources can be utilized for breeding applications. Among others, one limiting factor is the absence of phenotyping platforms allowing the analysis of such interactions. RESULTS: We developed a system that is able to (a) monitor root and shoot growth synchronously, (b) investigate their dynamic responses and (c) analyse the effect of heterogeneous N distribution to parts of the root system in a split-nutrient setup with a throughput (200 individual maize plants at once) sufficient for mapping of quantitative trait loci or for screens of multiple environmental factors. In a test trial, 24 maize genotypes were grown under split nitrogen conditions and the response of shoot and root growth was investigated. An almost double elongation rate of crown and lateral roots was observed under high N for all genotypes. The intensity of genotype-specific responses varied strongly. For example, elongation of crown roots differed almost two times between the fastest and slowest growing genotype. A stronger selective root placement in the high-N compartment was related to an increased shoot development indicating that early vigour might be related to a more intense foraging behaviour. CONCLUSION: To our knowledge, RADIX is the only system currently existing which allows studying the differential response of crown roots to split-nutrient application to quantify foraging behaviour in genome mapping or selection experiments. In doing so, changes in root and shoot development and the connection to plant performance can be investigated.

High-resolution quantification of root dynamics in split-nutrient rhizoslides reveals rapid and strong proliferation of maize roots in response to local high nitrogen.

The plant's root system is highly plastic, and can respond to environmental stimuli such as high nitrogen (N) in patches. A root may respond to an N patch by selective placement of new lateral roots, and therewith increases root N uptake. This may be a desirable trait in breeding programmes, since it decreases NO3(-) leaching and N2O emission. Roots of maize (Zea mays L.) were grown without N in split-nutrient rhizoslides. One side of the slides was exposed to high N after 15 d of root development, and root elongation was measured for another 15 d, described in a time course model and parameterized. The elongation rates of crown axile roots on the N-treated side of the plant followed a logistic increase to a maximum of 5.3cm d(-1); 95% of the maximum were reached within 4 d. At the same time, on the untreated side, axile root elongation dropped linearly to 1.2cm d(-1) within 6.4 d and stayed constant thereafter. Twice as many lateral roots were formed on the crown axis on the N side compared to the untreated side. Most strikingly, the elongation rates of laterals of the N side increased linearly with most of the roots reaching an asymptote ~8 d after start of the N treatment. By contrast, laterals on the side without N did not show any detectable elongation beyond the first day after their emergence. We conclude that split-nutrient rhizoslides have great potential to improve our knowledge about nitrogen responsiveness and selection for contrasting genotypes.

Rhizoslides: paper-based growth system for non-destructive, high throughput phenotyping of root development by means of image analysis.

BACKGROUND: A quantitative characterization of root system architecture is currently being attempted for various reasons. Non-destructive, rapid analyses of root system architecture are difficult to perform due to the hidden nature of the root. Hence, improved methods to measure root architecture are necessary to support knowledge-based plant breeding and to analyse root growth responses to environmental changes. Here, we report on the development of a novel method to reveal growth and architecture of maize root systems. RESULTS: The method is based on the cultivation of different root types within several layers of two-dimensional, large (50 × 60 cm) plates (rhizoslides). A central plexiglass screen stabilizes the system and is covered on both sides with germination paper providing water and nutrients for the developing root, followed by a transparent cover foil to prevent the roots from falling dry and to stabilize the system. The embryonic roots grow hidden between a Plexiglas surface and paper, whereas crown roots grow visible between paper and the transparent cover. Long cultivation with good image quality up to 20 days (four fully developed leaves) was enhanced by suppressing fungi with a fungicide. Based on hyperspectral microscopy imaging, the quality of different germination papers was tested and three provided sufficient contrast to distinguish between roots and background (segmentation). Illumination, image acquisition and segmentation were optimised to facilitate efficient root image analysis. Several software packages were evaluated with regard to their precision and the time investment needed to measure root system architecture. The software 'Smart Root' allowed precise evaluation of root development but needed substantial user interference. 'GiaRoots' provided the best segmentation method for batch processing in combination with a good analysis of global root characteristics but overestimated root length due to thinning artefacts. 'WhinRhizo' offered the most rapid and precise evaluation of root lengths in diameter classes, but had weaknesses with respect to image segmentation and analysis of root system architecture. CONCLUSION: A new technique has been established for non-destructive root growth studies and quantification of architectural traits beyond seedlings stages. However, automation of the scanning process and appropriate software remains the bottleneck for high throughput analysis.

Phase III, randomized, double-blind, placebo-controlled trial of gemcitabine/cisplatin alone or with sorafenib for the first-line treatment of advanced, nonsquamous non-small-cell lung cancer.

PURPOSE: This trial evaluated the efficacy and safety of sorafenib plus gemcitabine/cisplatin in chemotherapy-naive patients with unresectable stage IIIB to IV nonsquamous non-small-cell lung cancer (NSCLC). PATIENTS AND METHODS: Between February 2007 and March 2009, 904 patients were randomly assigned to daily sorafenib (400 mg twice a day) or matching placebo plus gemcitabine (1,250 mg/m(2) per day on days 1 and 8) and cisplatin (75 mg/m(2) on day 1) for up to six 21-day cycles. Because of safety findings from the Evaluation of Sorafenib, Carboplatin and Paclitaxel Efficacy in NSCLC (ESCAPE) trial, patients with squamous cell histology were withdrawn from the trial in February 2008 and excluded from analysis. The primary end point was overall survival (OS), and secondary end points included progression-free survival (PFS) and time-to-progression (TTP). RESULTS: The primary analysis population consisted of 772 patients (sorafenib, 385; placebo, 387); the two groups had similar demographic and baseline characteristics. Median OS was similar in the sorafenib and placebo groups (12.4 v 12.5 months; hazard ratio [HR], 0.98; P = .401). By investigator assessment, sorafenib improved median PFS (6.0 v 5.5 months; HR, 0.83; P = .008) and TTP (6.1 v 5.5 months; HR, 0.73; P < .001). Grade 3 to 4 drug-related adverse events more than two-fold higher in the sorafenib group included hand-foot skin reaction (8.6% v 0.3%), fatigue (7.3% v 3.6%), rash (5.7% v 0.5%), and hypertension (4.2% v 1.8%). No unexpected toxicities were observed. CONCLUSION: This study did not meet its primary end point of improved OS when sorafenib was added to first-line gemcitabine/cisplatin in patients with advanced nonsquamous NSCLC. Identification of predictive biomarkers is warranted in future trials of sorafenib.

[Miniscrews in orthodontics]. / Les minivis en orthodontie.

In recent years, miniscrews have come to occupy an ever greater place in orthodontic treatment plans. Today, we now know how to successfully deploy these particularly adaptable anchorage devices. The benefits of miniscrews have led orthodontists to adopt them, all the more so as they do no damage in the event of failure. We present the indications which are more and more evidence-based although these anchorage devices are suitable for use in any situation. We also describe the different surgical and orthodontic stages designed to facilitate the insertion of miniscrews and ensure their success. Several treated clinical cases will illustrate the principles underpinning their use in a variety of clinical settings.

Connexin 43 gene expression in mice with cardiopulmonary developmental defects.

Gap junctions are vital for cellular integrity, including homeostasis, morphogenesis, differentiation and growth in normal development of organs such as heart. Connexin 43 (Cx43) is a major gap junction protein. Our cDNA microarray analysis of normal and nitrofen-exposed neonatal mice with hypoplastic lungs, associated congenital diaphragmatic hernia (CDH) and heart developmental defects showed up-regulation of Cx43. Our objective was to establish if cardiopulmonary defects in nitrofen-exposed mice may be linked to altered expression of the Cx43 gene. We addressed our objective by performing northern blot analysis, real-time RT-PCR, immunoblotting and immunohistochemistry by localizing Cx43 in hearts and lungs of normal and nitrofen-exposed mice at different gestational stages. The data confirmed up-regulation of Cx43 expression in both hearts and lungs of CDH neonate mice and in lungs at other developmental stages except the pseudoglandular stage. However, Cx43 protein levels were either the same or less in hearts and lungs of nitrofen-exposed mice than in normal tissues except in pseudoglandular lungs. Different expressions of mRNA and protein suggest possible post-transcriptional or translational defects in Cx43. We observed dysmorphic hearts with exaggerated interventricular grooves and deep notches at the apex of the hearts in nitrofen-exposed fetal/neonatal mice; narrowed pulmonary out-flow and various degrees of craniofacial defects in 15-20% of the affected mice. Our data suggest a possible involvement of Cx43 in craniofacial, heart and lung defects in nitrofen-exposed mice. Such cardiopulmonary defects are also observed in human newborns with CDH. Thus, the murine data may help elucidate the pathways of cardiopulmonary defects in the human newborn condition.