Comprehensive Stress Stability Studies Reveal the Prominent Stability of the Liquid-Formulated Biotherapeutic Asymmetric Monovalent Bispecific IgG1 Monoclonal Antibody Format.

The developed asymmetric monovalent bispecific IgG1 or Duet monoclonal antibody (Duet mAb) has two distinct fragment antigen-binding region (Fab) subunits that target two different epitope specificities sequentially or simultaneously. The design features include unique engineered disulfide bridges, knob-into-hole mutations, and kappa and lambda chains to produce Duet mAbs. These make it structurally and functionally complex, so one expects challenging developability linked to instability, degradation of products and pathways, and limited reports available. Here, we have treated the product with different sources of extreme stress over a lengthy period, including varying heat, pH, photo stress, chemical oxidative stress, accelerated stress in physiological conditions, and forced glycation conditions. The effects of different stress conditions on the product were assessed using various analytical characterization tools to measure product-related substances, post-translational modifications (PTMs), structural integrity, higher-order disulfide linkages, and biological activity. The results revealed degradation products and pathways of Duet mAb. A moderate increase in size, charge, and hydrophobic variants, PTMs, including deamidation, oxidation, isomerization, and glycation were observed, with most conditions exhibiting biological activity. In addition, the characterization of fractionated charge variants, including deamidated species, showed satisfactory biological activity. This study demonstrated the prominent stability of the Duet mAb format comparable to most marketed mAbs.

Successful Development of Nonclinical Anti-Drug Antibody Assays to Support Zinpentraxin Alfa Reproductive Toxicology Studies.

Immunogenicity assessment is an essential part of biotherapeutic drug development. While the immune response in animals is not always representative of the human immune response, immunogenicity data obtained in animal models is still informative for the evaluation of drug exposure and safety. The most common assay format used for the detection of anti-drug antibodies (ADAs) in preclinical and clinical studies is the bridging format. The advantage of this method is that it can detect all antibody isotypes generated against the therapeutic. However, the method development can be time-consuming and labor-intensive, due to the need for labeling of the drug which is used both as capture and detection. Various generic ADA assays have been successfully implemented to overcome these disadvantages and to enable faster assay development timelines to support nonclinical toxicology studies. Here, we describe the challenges in the development of an assay to detect antibodies to zinpentraxin alfa, a recombinant human pentraxin-2, in rabbit and rat toxicology studies. Our initial efforts to develop a bridging assay failed, prompting us to develop a method adapted from generic assay formats to detect anti-zinpentraxin alfa antibodies in the serum of different species with minimal optimization. However, while the general assay format remained similar, assay reagents were adapted between the different species, resulting in the development of two distinct assays for the detection of ADAs in rat and rabbit. Here, we share the final development/validation data and the immunogenicity study results. Our work highlights the need for the evaluation of alternate assay formats when evaluating novel drug modalities.

Repeat-dose and embryo-fetal developmental toxicity of zinpentraxin alfa.

Zinpentraxin alfa is a recombinant human pentraxin-2 (PTX-2) developed for the treatment of various fibrotic diseases with the hypothesis that supplementing endogenous PTX-2 levels through intravenous administration should increase its regulatory capacity in circulation and at the site of disease, thereby promoting healing and reducing fibrosis. Zinpentraxin alfa has been studied in various clinical trials, particularly in patients with idiopathic pulmonary fibrosis, where it has demonstrated efficacy in slowing decline in lung function in a phase 2 study. In the present investigation, we summarize findings from 14-day repeat-dose toxicity studies in rats and cynomolgus monkeys supporting early clinical development of zinpentraxin alfa. In addition, we also describe the findings from the embryo-fetal developmental (EFD) studies conducted in rats and rabbits, since the intended fibrosis patient population may include patients of childbearing potential. Zinpentraxin alfa was well tolerated by rats and monkeys in general toxicity studies with no treatment-related adverse effects, as well as by pregnant rats over the same dose range in a definitive EFD study. In contrast, substantial toxicity was observed in a rabbit dose-range-finder EFD study. Zinpentraxin alfa was poorly tolerated by pregnant rabbits and effects on the dams correlated with post-implantation fetal losses. The disparate effects of zinpentraxin alfa on embryo-fetal development between the two species suggests a potential unknown biological function of PTX-2 in pregnancy in the rabbit, which may be relevant to humans. Our findings warrant the consideration for highly effective contraceptive measures to avoid pregnancy in patients enrolled in clinical studies with zinpentraxin alfa.

Fostering Animal Welfare and Advancing 3Rs Principles through the Establishment of a 3Rs Advisory Group.

Based on the current state of science, the use of animals remains essential in bringing safe and effective medicines to patients. Respect for laboratory animal welfare and the application of 3Rs principles (the replacement, reduction, and refinement of animal use in research) are a priority throughout the pharmaceutical industry. Given the rapid pace of development, technological progress, and the emergence of new-approach methodologies (NAMs) in the field of biomedical research, maintaining a leading position in scientific advancements with a focus on the principles of replace, reduce, and refine (3Rs) can be quite challenging. To effectively address these challenges and sustain a prominent position in the scientific community, organizations can derive significant advantages from establishing an internal 3Rs advisory group (3Rs AG). The primary objective of a 3Rs AG is to stay at the forefront of the knowledge of best practices related to the 3Rs principles in the industry. This group plays a crucial role in fostering innovation and facilitating the seamless integration and implementation of 3Rs principles into a company's policies and procedures. The thoughtful reduction in and replacement of animal studies and the refinement of study designs and practices, enabled by a 3Rs AG, can minimize animal use as well as guide resources and positively impact study and data quality. This article provides guidance on how to establish a successful and impactful 3Rs AG.

Learning Harmony: Medical Student Reflections on the Intersection of the Arts & Humanities and Medicine, A Mixed Methods Study.

Background: The arts and humanities form a critical part of medical education. In this study, we explore medical students' reflections following an arts and humanities experience. An intensive day and a half long program focused on music and reflection was designed for first-year students at Harvard Medical School. Methods: Students completed an evaluation of the experience with both open-ended and Likert scale questions. Data were analyzed using a mixed methods approach. Descriptive statistics were used to analyze quantitative data and inductive content analysis for qualitative data. Results: 168 first-year medical and dental students participated in the activity. Survey response rate was 73% (n =122). Quantitatively, the overall quality of the experience was assessed at a mean value of 4.86 points (SD = 0.37 points) out of a maximum of 5, with 5 being excellent. The qualitative evaluation illustrated how the arts and humanities experience encouraged students to reflect on their leadership and doctoring skills, taking a holistic approach to their medical education, and integrating the lessons of the arts and humanities into their medical practice. Conclusion: The arts and humanities program encouraged student reflection on profound questions in medicine related to empathy, vulnerability, and authenticity. This experience broadened students' perspectives regarding the relationship between medicine and the arts and humanities.

High-titer post-vaccine COVID-19 convalescent plasma for immunocompromised patients during the first omicron surge.

BACKGROUND: Transplant and hematologic malignancy patients have high Coronavirus disease 2019 (COVID-19) mortality and impaired vaccination responses. Omicron variant evades several monoclonal antibodies previously used in immunocompromised patients. Polyclonal COVID-19 convalescent plasma (CCP) may provide broader neutralizing capacity against new variants at high titers. Vaccination increases severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) titer in convalescent donors. METHODS: We conducted a retrospective chart review of hospitalized immunocompromised patients with COVID-19 who received high-titer CCP during the first omicron surge, collected from vaccinated donors within 6 months of pre-omicron COVID-19. Data on safety and outcomes were extracted. RESULTS: A total of 44 immunocompromised patients were included, 59.1% with solid organ transplant, 22.7% with hematopoietic cell transplant, 11.4% with hematologic malignancy, and 6.8% with autoimmune disease. Overall, 95% of CCP units transfused were from recently recovered and vaccinated donors and had SARS-CoV-2 antibody results 8- to 37-fold higher than the Food and Drug Administration's cutoff for high-titer CCP. There were two mild transfusion reactions. A total of 30-day mortality was 4.5%. There were no differences in 100-day mortality by underlying diagnosis, levels of immunosuppression, and timing of CCP administration. Patients with higher immunosuppression had significantly higher mean World Health Organization clinical progression scores at 30-day post-CCP compared to those with lower immunosuppression. CONCLUSIONS: CCP is a safe, globally available treatment for immunocompromised patients with COVID-19. Mortality was lower in our cohort than that of COVID-19 patients with similar immunocompromising conditions. Post-vaccine CCP with very high titers should be prioritized for study in immunocompromised patients. Post-vaccine CCP has the potential to keep pace with new variants by overcoming mutations at sufficiently high titer.

The Harvard Macy Institute Art Museum-based Health Professions Education Fellowship: Transformational faculty development through the arts.

Museum-based education for health professionals can lead to a variety of important learning outcomes within the domain of skills development, personal insight, perspective-taking and social advocacy. The Harvard Macy Institute's Art Museum-based Health Professions Education Fellowship was designed to develop faculty expertise in art museum-based practices, encourage scholarship, and cultivate a cohesive and supportive community of educators. The Fellowship was piloted from January to May 2019 with twelve interprofessional Fellows. Two in-person experiential sessions were held at Boston-area museums with intervening virtual learning. Fellows were introduced to a variety of approaches used in art museum-based education and developed a project for implementation at their home institution. A qualitative formative evaluation assessed immediate and 6-month post-Fellowship outcomes. Outcomes are reported in four categories: (1) Fellows' personal and professional development; (2) Institutional projects and curriculum development; (3) Community of practice and scholarly advancement of the field; and (4) Development of Fellowship model. A follow-up survey was performed four years after the conclusion of the pilot year, documenting Fellows' significant accomplishments in museum-based education, reflections on the Fellowship and thoughts on the future of the field.

A Comparison of Emotional Triggers for Eating in Men and Women with Obesity.

OBJECTIVE: Emotional eating (EE) is prevalent in people seeking obesity treatment and is a contributor to poor weight loss outcomes. We aimed to delineate the emotions most associated with this type of eating, and whether they differ by sex in people undergoing obesity treatment. METHODS: A cross-sectional study recruiting 387 adults from a hospital obesity management service. Emotional eating was measured using the Emotional Eating Scale (EES). Separate analyses included all participants, and those undergoing lifestyle interventions alone or in combination with obesity medication and/or bariatric surgery. RESULTS: A total of 387 people (71% women) participated in the study (n = 187 receiving lifestyle modification alone; n = 200 in combination with additional treatments). Feeling 'bored' was most commonly and most strongly associated with the urge to eat, regardless of sex or treatment. Women had higher scores for total EES, for subscales of depression and anger, and individual feelings of 'blue', 'sad' and 'upset' compared to men. CONCLUSIONS: Understanding why certain emotions differentially trigger an urge to eat in men and women, and finding strategies to break the link between boredom and eating may enable better personalisation of lifestyle interventions for people with obesity.

Validated transport conditions maintain the quality of washed red blood cells.

BACKGROUND: Washing red blood cell (RBC) units prior to transfusion is indicated for certain patients. In the United States, units stored at 1°C-6°C or transported at 1°C-10°C are available for issue up to 24 h, if not used immediately. The washing procedure commonly utilizes room temperature saline resulting in units starting out above the allowed temperature range. This leads to wastage if units are issued and returned too quickly before having a chance to equilibrate in a transport cooler. STUDY DESIGN AND METHODS: Here we performed an experimental study of washed RBC quality comparing "ideal" storage conditions in a blood bank refrigerator to a "real-world" simulation of unit transport, including holding in a transport cooler. Twelve RBC units were washed and allocated evenly into either condition. RESULTS: Measurements at 0, 1, 3, 6, 12, and 24 h post-washing revealed that placement in a transport cooler was associated with higher unit temperature prior to 12 h (p = .013) with a maximum difference of 9.3°C. Despite this difference, several measures of unit quality including extracellular potassium, pH, lactate, and free hemoglobin were indistinguishable between conditions (p = .382, .224, .286, .691, respectively). We selected half of the tested units from our irradiated inventory and confirmed increased potassium leak (p < .001) and accumulation of free hemoglobin (p = .012) in irradiated units. DISCUSSION: Washed units stored under approved transport conditions are acceptable to return to inventory up to 24 h after washing and we provide a prediction interval-based temperature threshold for rejecting these units, permitting reduced waste.

Evolution of paediatric eating disorders in Singapore: a historical cohort study.

OBJECTIVE: Most eating disorders (EDs) develop during adolescence, impacting a critical period of development. There is limited research on EDs in children in Singapore or the rest of South-East (SE) Asia. DESIGN: We analysed a hospital-based cohort of paediatric patients (≤18 years) with EDs (n=177) in Singapore between 2011 and 2021. Historical trends, over three decades, were obtained by comparison with two previously published Singapore studies. RESULTS: Of the 177 patients, the majority 158 (89%) were females, with anorexia nervosa (AN) 151 (85%). The mean age at diagnosis was 14.6 (SD 1.8) years. For AN, the mean duration of illness before diagnosis was 8.3 (SD 6.3) months and this has decreased by 8.4 months (95% CI 4.5 to 12.3 months, p=<0.0001) from the 2003 to 2010 cohort, and 17.7 months (95% CI 12.6 to 22.8 months, p=<0.0001) from the 1994 to 2002 cohort. Avoidant/restrictive food intake disorder (ARFID) cases are increasing, and the clinical profile differs from other EDs. Since family-based therapy (FBT) was introduced for patients with AN, the remission rate at 1 year improved from 30% to 79%, and time to remission has decreased from 16 to 7.5 months. CONCLUSIONS: AN is the most common ED in paediatric patients in Singapore. Over the past three decades, EDs are being diagnosed earlier. FBT has emerged as the most effective treatment for AN. ARFID is being diagnosed more frequently. Data suggest that EDs are prevalent and increasing among adolescents in SE Asia. Singapore is a good test case for SE Asia, but research and attention to the problem in the region is needed.

Brokering System Change: A Logic Model of an Intermediary-Purveyor Organization for Behavioral Health Care.

The improvement of systems of care has long been undermined by the gap between the availability and routine use of evidence-based interventions (EBIs). Researchers, implementation specialists, and service system stakeholders have created intermediary-purveyor organizations (IPOs) to facilitate EBI uptake and sustainment. To date, little theoretical or empirical scholarship has articulated stakeholder-driven processes among individuals such as service system program leaders, frontline service providers, service recipients, and academic and clinical experts that IPOs need to advance sustainable system change. The authors of this Open Forum outline a model of IPO inputs, objectives, and impacts while highlighting key issues that IPOs face as they contend with complex system change. Areas of future inquiry into partnership processes, IPO activities, and quality of care are discussed.

Breaking constraint of mammalian axial formulae.

The vertebral column of individual mammalian species often exhibits remarkable robustness in the number and identity of vertebral elements that form (known as axial formulae). The genetic mechanism(s) underlying this constraint however remain ill-defined. Here, we reveal the interplay of three regulatory pathways (Gdf11, miR-196 and Retinoic acid) is essential in constraining total vertebral number and regional axial identity in the mouse, from cervical through to tail vertebrae. All three pathways have differing control over Hox cluster expression, with heterochronic and quantitative changes found to parallel changes in axial identity. However, our work reveals an additional role for Hox genes in supporting axial elongation within the tail region, providing important support for an emerging view that mammalian Hox function is not limited to imparting positional identity as the mammalian body plan is laid down. More broadly, this work provides a molecular framework to interrogate mechanisms of evolutionary change and congenital anomalies of the vertebral column.

Active surveillance of serious adverse events following transfusion of COVID-19 convalescent plasma.

BACKGROUND: The reported incidence of adverse reactions following Coronavirus disease 2019 (COVID-19) convalescent plasma (CCP) transfusion has generally been lower than expected based on the incidence of transfusion reactions that have been observed in studies of conventional plasma transfusion. This raises the concern for under-reporting of adverse events in studies of CCP that rely on passive surveillance strategies. MATERIALS AND METHODS: Our institution implemented a protocol to actively identify possible adverse reactions to CCP transfusion. In addition, we retrospectively reviewed the charts of inpatients who received CCP at Stanford Hospital between May 13, 2020 and January 31, 2021. We determined the incidence of adverse events following CCP transfusion. RESULTS: A total of 49 patients received CCP. Seven patients (14%) had an increased supplemental oxygen requirement within 4 h of transfusion completion, including one patient who was intubated during the transfusion. An additional 11 patients (total of 18, 37%) had increased oxygen requirements within 24 h of transfusion, including 3 patients who were intubated. Six patients (12%) fulfilled criteria for transfusion-associated circulatory overload (TACO). CONCLUSION: Using an active surveillance strategy, we commonly observed adverse events following the transfusion of CCP to hospitalized patients. It was not possible to definitively determine whether or not these adverse events are related to CCP transfusion. TACO was likely over-diagnosed given overlap with the manifestations of COVID-19. Nevertheless, these results suggest that the potential adverse effects of CCP transfusion may be underestimated by reports from passive surveillance studies.

Comparison of two questionnaires for assessment of emotional eating in people undergoing treatment for obesity.

PURPOSE: Emotional eating may contribute to weight gain and difficulty with weight loss. Questionnaires are currently the primary method used to identify this behaviour but there is no gold standard for detecting emotional eating, making it difficult to know which questionnaire to use for this purpose. This study assesses two questionnaires validated for assessment of emotional eating in patients with obesity, with the aim of investigating their interchangeability in the clinical setting. METHODS: 387 adult participants were recruited from the obesity treatment service at a tertiary metropolitan hospital. Responses were obtained for the 25-item Emotional Eating Scale (EES) and the 4-item coping subscale of the Palatable Eating Motives Scale (PEMS). Agreement was analysed using quadratically weighted Cohen's κ scores. Substantial agreement was defined as κ 0.61-0.80. RESULTS: The median (interquartile range) body mass index and age of participants was 42.1 kg/m2 (36.4-48.9 kg/m2) and 51.6 years (41.1-61.4 years), respectively, and 70.5% of participants were female. The EES and PEMS were found to have substantial agreement (κ 0.71; 95% CI 0.65-0.76). Agreement remained substantial when analysing responses from men (0.61; 95% CI 0.47-0.73), women (0.73; 95% CI 0.67-0.79) and post-bariatric surgery patients (0.72; 95% CI 0.62-0.82) separately. CONCLUSION: Despite focusing on different elements of emotional eating behaviour, the substantial agreement between the EES and PEMS coping subscale suggests that they identify respondents' susceptibility to emotional eating with consistency, including in people who have undergone bariatric surgery. LEVEL V: Opinions of respected authorities, based on descriptive studies, narrative reviews, clinical experience, or reports of expert committees. CLINICAL TRIAL REGISTRATION: This observational study has not been registered as a clinical trial.

Patient deaths and medical residents: an Asian perspective.

OBJECTIVES: Death is a significant event that affects healthcare providers emotionally. We aimed to determine internal medicine (IM) and paediatric (PD) residents' responses and the impact on the residents following patient deaths, and to compare any differences between IM and PD residents. We also aimed to determine whether sufficient resources and measures were in place to support residents through their grief process. METHODS: This is a single-centre, cross-sectional study involving residents from IM and PD programmes from an academic tertiary hospital in Singapore. The residents completed a questionnaire regarding their responses and emotions after experiencing patient deaths. RESULTS: A total of 122 residents (85 IM and 37 PD, equally distributed between year 1 to year 4 of residency training) participated, with 100% response rate. Only half (57%) felt they would be comfortable treating a dying patient and 66.4% reported feeling sad following their patient's death. Most (79.5%) were not aware of support resources that were available and 82% agreed that formal bereavement training should be included in the residency curriculum. PD residents had more negative symptoms than IM residents, with poor concentration (PD 35.1% vs IM 16.5%, p=0.02) and lethargy (PD 35.1% vs IM 9.4%, p<0.01) being the most common. CONCLUSION: In our Asian context, residents are negatively affected by patient deaths, especially the PD residents. There is a need to incorporate relevant bereavement training for all residents.

Identifying stress-related eating in behavioural research: A review.

Stress is a commonly reported precipitant of overeating. Understanding the relationship between stress and food intake is important, particularly in view of the increasing prevalence of obesity. The purpose of this review is to examine how stress-related eating has been defined and measured in the literature to date. There are no established diagnostic criteria or gold standards for quantification of stress-related eating. Questionnaires relying on the accuracy of self-report are the mainstay of identifying people who tend to eat in response to stress and emotions. There is a paucity of clinical research linking objective measurements of stress and appetite with self-reported eating behaviour. Limitations of the methodological approaches used and the heterogeneity between studies leave significant knowledge gaps in our understanding of the mechanism of stress related eating, and how best to identify it. These issues are discussed, and areas for further research are explored.

Emotional eating in patients attending a specialist obesity treatment service.

OBJECTIVE: The prevalence of emotional eating (EE) has increased in the general population over past decades. There is limited information on how common EE is among people seeking obesity treatment. We aimed to estimate the proportion of people with EE, and strength of associations between a predefined set of factors and EE in people referred for obesity treatment. METHODS: Cross-sectional study recruiting 387 adults from a hospital obesity service. "Emotional eating" was defined as Emotional Eating Scale (EES) score ≥25. Strength of associations were estimated by boot-strapped quantile regression analysis. Results are presented as quantile difference (QD) of EES scores at the 25th, 50th or 75th quantile, and 95% confidence intervals (95%CI). RESULTS: The study population consisted of 71% women, with a median age of 52 years (interquartile range [IQR]: 42, 61), and a median body mass index of 42 kg/m2 (IQR: 37, 49). 187 participants were managed with lifestyle modification alone, 103 with the addition of obesity pharmacotherapy, 79 with bariatric surgery, and 18 with both bariatric surgery and medications. EE was reported by an estimated 58% (95%CI: 53, 63) of participants. Factors with the largest and most consistent magnitude of association with EES differences include age, sex, use of glucagon-like peptide-1 (GLP-1) agonists, history of sleeve gastrectomy and recent bariatric surgery. CONCLUSION: Emotional eating affected more than half of people referred for obesity treatment. Age, sex, use of GLP-1 agonists, history of sleeve gastrectomy and recent bariatric surgery had the strongest associations with EE. These findings allow hypothesis generation about the underlying physiological mechanisms behind emotional eating for investigation in future research.

A consensus statement on the use of angiotensin receptor blockers and angiotensin converting enzyme inhibitors in relation to COVID-19 (corona virus disease 2019).

There has been a lot of speculation that patients with coronavirus disease 2019 (COVID-19) who are receiving angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) may be at increased risk for adverse outcomes. We reviewed the available evidence, and have not found this to be the case. We recommend that patients on such medications should continue on them unless there is a clinical indication to stop their use.