Long-term high-dose immunoglobulin successfully treats Long COVID patients with pulmonary, neurologic, and cardiologic symptoms.

Introduction: Long COVID is the overarching name for a wide variety of disorders that may follow the diagnosis of acute SARS-COVID-19 infection and persist for weeks to many months. Nearly every organ system may be affected. Methods: We report nine patients suffering with Long COVID for 101 to 547 days. All exhibited significant perturbations of their immune systems, but only one was known to be immunodeficient prior to the studies directed at evaluating them for possible treatment. Neurological and cardiac symptoms were most common. Based on this data and other evidence suggesting autoimmune reactivity, we planned to treat them for 3 months with long-term high-dose immunoglobulin therapy. If there was evidence of benefit at 3 months, the regimen was continued. Results: The patients' ages ranged from 34 to 79 years-with five male and four female patients, respectively. All nine patients exhibited significant immune perturbations prior to treatment. One patient declined this treatment, and insurance support was not approved for two others. The other six have been treated, and all have had a significant to remarkable clinical benefit. Conclusion: Long-term high-dose immunoglobulin therapy is an effective therapeutic option for treating patients with Long COVID.

Impact of Compression and Small Cell Deployment on NB-IoT Devices Coverage and Energy Consumption with a Realistic Simulation Model.

In the last few years, Low-Power Wide-Area Network (LPWAN) technologies have been proposed for Machine-Type Communications (MTC). In this paper, we evaluate wireless relay technologies that can improve LPWAN coverage for smart meter communication applications. We provide a realistic coverage analysis using a realistic correlated shadow-fading map and path-loss calculation for the environment. Our analysis shows significant reductions in the number of MTC devices in outage by deploying either small cells or Device-to-Device (D2D) communications. In addition, we analyzed the energy consumption of the MTC devices for different data packet sizes and Maximum Coupling Loss (MCL) values. Finally, we study how compression techniques can extend the battery lifetime of MTC devices.

Association of financial assistance programs and time to completion of therapy in women receiving chemoradiation for cervical cancer.

We aimed to evaluate how the need for social services programs is associated with outcomes amongst patients with cervical cancer undergoing chemoradiation with a single institution, retrospective analysis of patients from January 1, 2015-July 31, 2018. Demographic, clinical, and social services utilization data were collected. Descriptive statistics and Chi-squared tests were performed. Kaplan-Meier curves estimated progression free (PFS) and overall survival (OS). Among 117 eligible patients, median household income was $45,782 ($19,771 - $96,222). There was no difference in stage among income cohorts. Uninsured/publically insured patients had a higher stage at diagnosis than those privately insured (p = 0.003). Patients used 0-5 assistance programs during treatment. 77.6% of low income versus 54.2% of high income patients utilized ≥1 program. Assistance with lodging was utilized more often in low than high income patients. (36.2% vs 15.7%, p = 0.013). 58.3% of patients completed therapy in less than 56 days. Patients who completed therapy in >56 days utilized 1.44 social services while patients completing in ≤56 days used 1.06 (p = 0.102). Social security disability utilization trended towards completion times >56 days (p = 0.064). There was no difference in PFS or OS based on income or social services utilized. Financial toxicities associated with therapy are not limited to uninsured/publically insured or low income patients as over 50% of high income patients utilized at least one service. Additionally, the trend towards significance between enrollment in disability and completion of chemoradiation >56 days may highlight a group of at risk patients who need additional support.

The Inflammatory Cytokine IL-21 is Expressed by Splenic Neutrophils in Response to Transplantation of Allogeneic Cells.

We have previously reported that GR-1 neutrophil/monocytes rose dramatically in the spleen, peaked by day 7 and declined through day 14. This period corresponded to the peak of acute Graft-Versus-Host Disease (aGVHD) in BALB/c mice transplanted with allogeneic donor cells. We now asked: what cytokines did these splenic neutrophil/monocytes express on day 7 and 14 post transplant? BALB/c mice were transplanted with allogeneic B6 or syngeneic BALB/c donor cells. Long term survival was recorded through day 31. Other groups were sacrificed on days 3, 5, 7, 14, 21 and 31 days post transplant to record the total number of cells in the spleens and their phenotypes. Neutrophils were isolated from the spleens of mice transplanted with B6 and BALB/c cells on days 7 and 14. Daily body weight demonstrated a transient drop in the syngeneic transplants on day 2 but a much greater drop with its nadir at day 7 and never fully recovering through 31 days. CD8/CD4 T lymphocytes peaked in the spleen on day 5 and were followed on day 7 by GR-I cells in all of the allogeneic transplants. In syngeneic transplants this early rise in lymphocytes did not occur and GR-1 cells peaked on day 14. Highly purified neutrophils were isolated in two separate experiments from the spleens on days 7 and 14 post transplant. In both experiments day 7 allogeneic neutrophils expressed significantly elevated levels of Interleukin-21 (IL-21) mRNA whereas the day 7 and 14 syngeneic cells expressed lower but significant levels of TNFα. Intracellular IL-21 was demonstrated in the allogeneic neutrophils on day 7 before and after in vitro stimulation. In conclusion Purified neutrophils isolated from the spleen on day 7, the early peak of allogeneic transplantation a GVHD, express high levels of IL-21 message and intracellular IL-21.

Pyrrolidine dithiocarbamate (PDTC) blocks apoptosis and promotes ionizing radiation-induced necrosis of freshly-isolated normal mouse spleen cells.

Ionizing radiation (IR) is a pro-oxidant that kills cells by both apoptotic and necrotic mechanisms. Pyrrolidine dithiocarbamate (PDTC) is a thiol-containing compound that may act either as a pro- or anti-oxidant depending on the experimental conditions. This study was designed to determine whether PDTC would reduce or enhance IR-induced cell death of freshly-isolated normal mouse B6/129 spleen cells (NMSC). We determined the effect of increasing doses of IR, PDTC alone and PDTC followed by IR on the viability of NMSC. Annexin V and propidium iodide (Annexin V/PI) staining demonstrated a dose and time-dependent relationship in which PDTC enhanced the percentage of IR-induced apoptotic/necrotic NMSC. Trypan blue dye inclusion confirmed that a loss of membrane integrity was occurring 1 h after incubation with PDTC plus IR. Reduction in the glutathione (GSH)/glutathione disulfide (GSSG) ratio and GSH demonstrated that both IR (8.5 Gy) and PDTC acted as pro-oxidants, but their mechanisms of action differed: In contrast to IR, which promoted p53 activation and caspase 3/7-mediated apoptosis, PDTC inhibited IR-induced p53 and caspase 3/7 activity. However, PDTC increased H(2)O(2) formation and necrosis, resulting in an overall increase in IR-induced cell death. Catalase prevented the PDTC-induced increase in IR cytotoxicity implicating the generation of H(2)O(2) as a major factor in this mechanism. These results demonstrate that in NMSC PDTC acts as pro-oxidant and enhances IR-induced cell cytotoxicity by increasing H(2)O(2)formation and thiol oxidation. As such, they strongly suggest that the use of PDTC as an adjunct to reduce radiation toxicity should be avoided.

The manganese superoxide dismutase mimetic, M40403, protects adult mice from lethal total body irradiation.

Over-expression of manganese superoxide dismutase (MnSOD) protects tissues from radiation. M40403 is a stable non-peptidyl mimetic of MnSOD that crosses cell membranes and is effective in reducing experimental inflammation. Male BALB/c mice were injected intraperitoneally (i.p.) and subcutaneously (s.c.) with M40403, 30 min before 6.5, 7.5 and 8.5 Gy total body irradiation (TBI). Whereas all control injected mice died after receiving 8.5 Gy TBI by day 17, 30 day survival of mice pre-treated i.p. with 40, 30, 20 or 10 mg/kg was 100%, 90%, 81% and 25%, respectively. The Dose Reduction Factor 50/30 for animals treated with 30 mg M40403 s.c. 30 min prior to TBI was 1.41. Decreased apoptosis of the large and particularly the small bowel and marked recovery of both lymphoid and hematopoietic tissues occurred in the M40403 pre-treated animals. M40403 is effective in reducing TBI-induced tissue destruction and has potential as a new radioprotective agent.

T10B9 monoclonal antibody: a short-acting nonstimulating monoclonal antibody that spares gammadelta T-cells and treats and prevents cellular rejection.

T10B9.1A-31/MEDI-500 is a nonmitogenic immunoglobulin M kappa murine monoclonal antibody (mAb) directed against the alpha-beta (alphabeta) heterodimer of the T-lymphocyte receptor complex. The hybridoma was first produced by fusing spleen cells from BALB/C mice immunized with human peripheral blood T-lymphocytes with SP2/O-Ag14 mutant myeloma cells. The mAb is produced and purified using multistep ion exchange and molecular sieve chromatography protocols. T10B9 has been used successfully to treat acute cellular rejection in renal transplantation and as an immunosuppression induction agent in heart and simultaneous kidney-pancreas transplantation. Because T10B9 is nonmitogenic and causes minimal cytokine release, both treatment of rejection and induction of immunosuppression were accomplished with significantly fewer and milder untoward effects (cytokine release syndrome) than its comparator OKT3. Since T10B9 is directed against the alphabeta heterodimer of the CD3 epitope, it spares the gamma delta (gammadelta) region. These gamma delta (gammadelta) T cells have a unique role in the immune response controlling many serious human diseases and perhaps facilitating the development of immunologic tolerance. T10B9 has a relatively short duration of action, depleting T cells for only 10 to 14 days, unlike the protracted depletion seen with thymoglobulin and Campath-1H. There is no B-lymphocyte depletion with T10B9 as there is with both of the aforementioned reagents. The lack of prolonged lymphocyte depletion may account for less infection observed with T10B9 treatment.

Radiation mitigation effect of cultured mushroom fungus Hirsutella Sinensis (CorImmune) isolated from a Chinese/Tibetan herbal preparation -Cordyceps Sinensis.

PURPOSE: This study was carried out to test the hypothesis that the anti-oxidant and growth promoting properties of the cultured mushroom fungus Hirsutella sinensis (CorImmune) of Cordyceps sinensis mitigate radiation injury in mice. MATERIALS AND METHODS: BALB/c mice received total body irradiation (TBI) followed by treatment with CorImmune. The effect of CorImmune on lymphoid tissue, spleen and blood cells as well as survival and hematopoietic recovery was compared to normal saline treated controls. RESULTS: CorImmune administered beginning 2 hours after a lethal dose of TBI significantly improved survival: 55% in the CorImmune group vs. 0% in the saline control (p < 0.0001). It increased normal leukocyte levels in a dose-dependent fashion. Animals treated with sub-lethal TBI and monitored for blood leukocyte recovery exhibited a return to normal baseline 3 weeks after TBI injury. In contrast, only 50% returned to normal baseline in the saline control group (p < 0.01). CorImmune also stimulated immune lymphocyte proliferation by nearly two-fold in a (3)H-thymidine incorporation assay compared to controls (p < 0.01). CONCLUSIONS: CorImmune significantly increased animal survival after a lethal dose of radiation, accelerated leukocyte recovery and stimulated immune lymphocyte proliferation. We conclude that CorImmune is effective as a radiation mitigator when administered after radiation injury.

P53 status influences regulation of HSPs and ribosomal proteins by PDTC and radiation.

Pyrrolidine dithiocarbamate (PDTC) is a thiol-containing compound that can act under varying conditions as an anti-oxidant or pro-oxidant. Utilizing microarrays, we determined the effect of PDTC +/- ionizing radiation (IR) on the expression of heat shock protein (HSP) genes in isolated B6/129 wild-type (WT) and p53-/- spleen cells. Extremely significant microarrays demonstrated that PDTC, but not IR, markedly up-regulated the expression of the majority of detectable HSP genes in WT and many to a significantly greater degree in p53-/- deficient cells. Determination of the glutathione/glutathione disulfide ratio indicated that PDTC was acting as a pro-oxidant under these conditions. From these data we conclude that the clinical use of "antioxidants" with radiotherapy or chemotherapy must be very carefully based on knowledge of the p53 status of their intended normal and tumor target cells.

Effect of graft-versus-host disease prophylaxis on 3-year disease-free survival in recipients of unrelated donor bone marrow (T-cell Depletion Trial): a multi-centre, randomised phase II-III trial.

BACKGROUND: Graft-versus-host disease (GVHD) reduces the efficacy of unrelated donor bone marrow transplantation in patients with lymphohaemopoietic malignancy. A multi-centre, randomised trial was undertaken to determine the effects of ex-vivo T-cell depletion versus methotrexate and cyclosporine immunosuppression on 3-year disease-free survival. METHODS: Between Mar 1, 1995, and Oct 31, 2000, 405 patients with lymphohaemopoietic malignancy, from 15 participating centres, were randomly assigned to undergo transplantation with either T-cell depleted marrow and cyclosporine A (TCD arm; n=201) or methotrexate and cyclosporine A after transplantation of T-replete marrow (M/C arm; n=204). The primary outcome was 3-year disease-free survival and was analysed by intention to treat. FINDINGS: Five patients died before transplantation. Seven in the TCD arm received T-replete grafts. Disease-free survival at 3 years was 27% (95% CI 21-33) and 34% (27-40) in recipients of TCD and M/C, respectively (p=0.16). TCD was associated with significantly more rapid neutrophil recovery (15 days vs 20 days, p<0.0001), less grade III-IV acute GVHD (18%vs 37%, p<0.0001), reduced grade III-IV toxicities (19%vs 29%, p=0.017), reduced duration of initial hospitalisation, but higher risk of chronic myelogenous leukaemia relapse (20%vs 7%, p=0.009) and cytomegalovirus infection (28%vs 17%, p=0.023) than was M/C. INTERPRETATION: Disease-free survival at 3 years did not differ between TCD and M/C groups. Relapse and opportunistic infection are important obstacles to successful unrelated donor bone marrow transplantation, irrespective of the method of GVHD prophylaxis used.

Use of a T cell-specific monoclonal antibody, T10B9, in a novel allogeneic stem cell transplantation protocol for hematologic malignancy high-risk patients.

To reduce the toxicity of traditional conditioning regimens for allogeneic stem cell transplantation (allo-SCT), we used single-agent chemotherapy conditioning with either busulfan (total cumulative dose, 16 mg/kg) or melphalan (200 to 240 mg/m 2 ), followed by the anti-T cell-specific monoclonal antibody T10B9 (MEDI-500) daily for 3 days. T cell-replete SCT was performed from HLA-identical sibling donors. Acute graft-versus-host disease (aGVHD) prophylaxis consisted of 7 additional days of T10B9 and delayed onset of cyclosporine (ie, on day +4 or +5). Twenty-six high-risk hematologic malignancy patients were entered onto this study. All 24 patients who survived longer than 8 days engrafted, although 1 patient experienced late graft failure. Deaths occurred in 21 of 26 patients because of infection (n = 7), progression/recurrence of primary disease (n = 6), aGVHD (n = 4), regimen-related toxicity (n = 1), and other causes (n = 3). Five of these patients are enjoying disease-free survival with a median survival of 1193 days after allo-SCT. The conditioning regimen induced modulation of surface expression of CD3 (but not CD4 or CD8) and was associated with decreasing tumor necrosis factor-alpha (but not interleukin-6) serum levels. In conclusion, single-agent chemotherapy conditioning with T10B9 produced durable engraftment and long-term survival in some patients who would not have qualified for a traditional allo-SCT.

Activation of nuclear factor kappaB In vivo selectively protects the murine small intestine against ionizing radiation-induced damage.

Exposure of mice to total body irradiation induces nuclear factor kappaB (NFkappaB) activation in a tissue-specific manner. In addition to the spleen, lymph nodes, and bone marrow, the tissues that exhibit NFkappaB activation now include the newly identified site of the intestinal epithelial cells. NFkappaB activated by total body irradiation mainly consists of NFkappaB p50/RelA heterodimers, and genetically targeted disruption of the NFkappaB p50 gene in mice significantly decreased the activation. By comparing tissue damage and lethality in wild-type and NFkappaB p50 knockout (p50-/-) mice after they were exposed to increasing doses of total body irradiation, we additionally examined the role of NFkappaB activation in total body irradiation-induced tissue damage. The results show that p50-/- mice are more sensitive to total body irradiation-induced lethality than wild-type mice (LD50/Day 7: wild-type = 13.12 Gy versus p50-/- = 7.75 Gy and LD50/Day 30: wild-type = 9.31 Gy versus p50-/- = 7.81 Gy). The increased radiosensitivity of p50-/- mice was associated with an elevated level of apoptosis in intestinal epithelial cells and decreased survival of the small intestinal crypts compared with wild-type mice (P < 0.01). In addition, RelA/TNFR1-deficient (RelA/TNFR1-/-) mice also exhibited a significant increase in intestinal epithelial cell apoptosis after they were exposed to total body irradiation as compared with TNFR1-deficient (TNFR1-/-) mice (P < 0.01). In contrast, no significant increase in total body irradiation-induced apoptosis or tissue injury was observed in bone marrow cells, spleen lymphocytes, and the liver, heart, lung, and kidney of p50-/- mice in comparison with wild-type mice. These findings indicate that activation of NFkappaB selectively protects the small intestine against ionizing radiation-induced damage.

Human leukocyte antigens DR and AB and kidney retransplantation.

BACKGROUND: Although class II human leukocyte antigen (HLA) DR mismatching has been shown to demonstrate a significant effect on kidney regraft survival, it has not generally been clinically emphasized. METHODS: We examined 2,574 kidney retransplants performed in Southeastern Organ Procurement Foundation centers between January 1988 and December 1997 in which there was ABDR typing on both donor and recipient and pretransplant panel reactive antibody (PRA) data. RESULTS: Cox regression of multiple variables demonstrated that the most important risk factors in descending order were DR mismatching, non-white recipient, female donor, PRA as a continuous variable, and cold ischemia time. Although DR mismatching demonstrated a significant effect in white recipients, the impact was much greater in non-white recipients. In both groups, zero to four AB mismatches demonstrated no significant effect on regraft survival if DR was matched and only a minimal effect when DR was mismatched. The discrepancy of these findings with reports that demonstrate a stepwise decrease in regraft survival on the basis of the total zero to six ABDR mismatches was explained by the fact that the zero to six ABDR mismatches are a combination of AB mismatches with little effect and DR mismatches with a major effect. Regraft survival decreased progressively in association with increasing PRA. CONCLUSIONS: DR matching is critically important in kidney retransplantation. There was no significant difference in survival of zero ABDR mismatched retransplants compared with one to four AB and zero DR mismatched retransplants. On the other hand, kidney graft survival of all one to four AB and zero DR mismatches exceeded that of one or two DR mismatched retransplants. We propose that the association of decreasing regraft survival with increasing PRA reflects undetected sensitization to class II, and possibly class I, antigens.

Prospective trial of a predictive algorithm to transplant cadaver kidneys into highly sensitized patients.

BACKGROUND: The difficulty of transplanting sensitized patients increases proportionally to the panel reactive antibody (PRA) titer. Because of the high likelihood of a positive final crossmatch, these patients are often excluded from a prospective transplant unless there is a 0 HLA-A, -B, -DR mismatch. To address this problem, we developed a computerized algorithm, termed the Kentucky Antibody Testing System (KATS), that predicts class I HLA antigens that would be both "unacceptable" and "acceptable" to the recipient. This report describes the results of a prospective trial among voluntarily participating centers that agreed to share kidneys based on the KATS predictions for patients whose PRA exceeded 40%. METHODS: The results of three antibody screens on each patient were compared with the HLA phenotypes of the cells in the panel in 2x2 tables with calculation of chi-square and correlation coefficient statistics. Private, broad, and public antigens were identified and a list of acceptable and unacceptable antigens were entered into the UNOS computer for each patient listed in the KATS sharing algorithm. RESULTS: Of the total 418 patients meeting the inclusion/exclusion criteria, the largest single group submitted was Black-not-of-Hispanic-origin females. The mean PRA of the patients was 72%. The first transplant via KATS allocation was performed on March 8, 1997. Between that time and the last transplant on July 31, 2000, 145 kidneys were offered to the participating centers and 48 transplants were performed. Of the many reasons listed for not accepting an offer or not transplanting the shared kidney into its intended recipient, only two occurred because of a positive T cell crossmatch and six because of a positive B cell crossmatch. As compared to all other high PRA patients within Southeastern Organ Procurement Foundation who were transplanted during the study period, they were more likely to be non-Caucasian, to be less well matched for private HLA-A, B, and DR antigens, and to have waited for a longer time than the other groups. Although there was a higher incidence of delayed graft function, there was no significant difference in cold ischemia, rejection episodes, or patient or graft survival. CONCLUSIONS: We conclude that KATS, or some other system to prospectively identify a list of acceptable and unacceptable HLA antigens, could improve the access of highly sensitized patients to a successful kidney transplant.

Early effects of tribromoethanol, ketamine/xylazine, pentobarbitol, and isoflurane anesthesia on hepatic and lymphoid tissue in ICR mice.

We investigated the effects of various anesthetic agents on hepatic and splenic injury in mice. Three and six hours after intraperitoneal injection of TBE, intramuscular injection of ketamine/xylazine combination (K/X), intraperitoneal injection of pentobarbital (PB), and inhalation of isoflurane (IF), or intraperitoneal and intramuscular injection of control saline, mice were exsanguinated and serum was obtained for measurement of hepatic aspartate transaminase (AST), alanine transaminase (ALT) and gamma-glutamyltransferase (GGT). The spleen and liver also were obtained, and sections were examined by use of routine light microscopy for pathologic changes and for apoptosis, as determined by use of the in situ terminal deoxynucleotidyl transferase-mediated dUPT nick-end-labeling (TUNEL) histochemical analysis. Three hours after TBE or K/X administration, AST activity increased three- to fourfold above that in untreated and saline-injected control animals, and remained high at six hours. Administration of PB did not effect AST activity at three hours, but there was a significant increase at six hours. Activity of ALT was non-significantly increased three hours after TBE and K/X, but not PB administration. Administration of IF had no effect on hepatic enzyme activities, and GGT was not increased after administration of any of the agents. Markedly increased apoptosis was observed in splenic follicles and in hepatic Kupffer and endothelial cells at three hours after TBE and K/X administration, but apoptosis decreased to control levels by six hours. Increased apoptosis was not observed after IF administration. Administration of TBE and K/X causes injury to lymphocytes and to hepatic Kupffer and endothelial cells within three hours, and PB administration induces changes within six hours. Thus, use of these anesthetic agents should be avoided when experiments are being designed to test short-term effects of an experimental intervention on the spleen and possibly on all lymphoid tissues. In addition, they also should be avoided in experiments testing effects on hepatic tissue.