Effects of ophidiomycosis on movement, survival, and reproduction of eastern foxsnakes (Pantherophis vulpinus).

Ophidiomycosis (snake fungal disease) is caused by the fungal pathogen Ophidiomyces ophidiicola, which causes dermal lesions, occasional systemic infections, and in some cases, mortality. To better understand potential conservation implications of ophidiomycosis (i.e., population-level effects), we investigated its impacts on individual fitness in a population of endangered eastern foxsnakes (Pantherophis vulpinus). We tracked 38 foxsnakes over 6 years and quantified body condition, movement patterns, oviposition rates, and survival. Body condition, distance travelled, and oviposition rates were similar between snakes with and without ophidiomycosis. Interestingly, snakes that tested positive for the pathogen travelled farther, suggesting that movement through a greater diversity of habitats increases risk of exposure. Ophidiomycosis did not negatively affect survival, and most apparently infected snakes persisted in a manner comparable to snakes without ophidiomycosis. Only one mortality was directly attributed to ophidiomycosis, although infected snakes were overrepresented in a sample of snakes killed by predators. Overall, our results suggest that ophidiomycosis may have sublethal effects on eastern foxsnakes, but do not suggest direct effects on survival, ovipositioning, or viability of the study population.

Optimizing Reversal of Muscle Relaxation with Sugammadex to Accelerate Discharge Readiness in Operative Laryngoscopy: A Randomized Clinical Trial.

IMPORTANCE: Operative laryngoscopy is a commonly performed ambulatory procedure in patients with significant co-morbidity. Optimal anesthetics for surgical exposure with rapid return to baseline after the procedure enhances postoperative patient safety. OBJECTIVE: To determine whether sugammadex hastens recovery in patients undergoing operative laryngoscopy under general anesthesia with rocuronium-induced paralysis. DESIGN: Prospective clinical intervention randomized single-blinded, single-center study in an academic tertiary care center. Approved by the institutional review board and registered with ClinicalTrials.gov. SETTINGS: Single center tertiary care academic institution. PARTICIPANTS: 18 years or older, American Society of Anesthesiology physical status I-III with ability to give written informed consent undergoing operative laryngoscopy. INTERVENTION: Participants were randomized into two groups. Both groups received inhaled anesthetic: sevoflurane, remifentanil, and rocuronium at 0.6-1.2 mg/kg for intubation and anti-nausea prophylaxis. Group 1 received reversal with neostigmine (0.04 mg/kg) and glycopyrrolate (0.01 mg/kg). Group 2 received reversal with sugammadex (4 mg/kg). Vital signs were maintained at 20% of baseline in both groups. Post anesthesia care unit nurses were blinded to the reversal agent and were the evaluators of the discharge criteria and times. Primary end point was time to extubation after the procedures and secondary end points were: Subjective interpretation of surgical conditions by the surgeon, hemodynamic, respiratory parameters, anesthetics, and opioids used, operative time, and duration to achieve discharge readiness. RESULTS: A total of eighty-four participants, who were similar in age, sex, and weight in both groups. The primary end point and secondary end points were similar except time to meet discharge criteria in the two groups. 65% in the sugammadex versus 35% in the neostigmine group met Aldrete criteria of 18 or higher on arrival at the post anesthesia care unit. CONCLUSIONS: Optimizing the anesthetic regimen, along with stable intraoperative hemodynamics and reversal with sugammadex improves discharge readiness in patients undergoing operative laryngoscopy.

SEASONAL AND INTERSPECIFIC VARIATION IN THE PREVALENCE OF OPHIDIOMYCES OPHIDIICOLA AND OPHIDIOMYCOSIS IN A COMMUNITY OF FREE-RANGING SNAKES.

Ophidiomycosis in snakes is caused by the fungus Ophidiomyces ophidiicola. Clinical signs associated with the disease range from minor skin lesions to severe swelling of the face. In some cases, the fungus invades the snake's underlying muscle and bone and internal organs; disease severity appears to peak during brumation. We quantified the prevalence of O. ophidiicola and ophidiomycosis in free-ranging snakes to explore seasonal variation in detection of the pathogen and disease. We collected skin swabs (n=464 samples) from seven species of free-ranging snakes (n=336) from Rondeau Provincial Park (Ontario, Canada) and tested the swabs for O. ophidiicola using quantitative PCR. We also assessed individuals for lesions consistent with ophidiomycosis and monitored changes in gross lesions over time in recaptured individuals. Eastern foxsnakes (Pantherophis vulpinus) had the highest prevalence of O. ophidiicola (24/84) and of lesions consistent with ophidiomycosis (34/84). On other species (Nerodia sipedon, Storeria dekayi, Thamnophis sirtalis, and Thamnophis sauritus), we detected the pathogen on only 4/229 snakes and observed gross lesions consistent with ophidiomycosis on 24/229 snakes. Body length of eastern foxsnakes was associated with detection of O. ophidiicola, suggesting that eastern foxsnakes' large size increases the risk of pathogen exposure relative to the other, smaller, species at our study site. Ophidiomyces ophidiicola and lesions consistent with ophidiomycosis were detected most frequently in eastern foxsnakes soon after emergence from brumation and less frequently later in the active season (O. ophidiicola: April=29.8%, October=3.9%; lesions: April=36.1%, October=5.5%). This decrease corresponded with resolution of lesions in 6/13 resampled eastern foxsnakes. Considering the seasonal cycle of O. ophidiicola and ophidiomycosis when planning disease surveillance research may improve detection probabilities for ophidiomycosis in Nearctic snakes.

A Mechanistic Understanding of Monoclonal Antibody Interfacial Protection by Hydrolytically Degraded Polysorbate 20 and 80 under IV Bag Conditions.

PURPOSE: Polysorbates (PS) contain polyoxyethylene (POE) sorbitan/isosorbide fatty acid esters that can partially hydrolyze over time in liquid drug products to generate degradants and a remaining intact PS fraction with a modified ester distribution. The degradants are composed of free fatty acids (FFAs) --primarily lauric acid for PS20 and oleic acid for PS80-- and POE head groups. We previously demonstrated that under IV bag agitation conditions, mAb1 (a surface-active IgG4) aggregation increased with increasing amounts of degradants for PS20 but not for PS80. The purpose of this work is to understand the mechanism behind this observation. METHODS: The surface tension of the remaining intact PS fraction without degradants was modeled and compared with that of enzymatically degraded PS solutions. Next, mAb1 aggregation in saline was measured in the presence of laurate and oleate salts during static storage. Lastly, colloidal and conformational stability of mAb1 in the presence of these salts was investigated through differential scanning fluorimetry and dynamic light scattering under IV bag solution conditions. RESULTS: The surface tension was primarily influenced by FFAs rather than the modified ester distribution of the remaining intact PS. MAb1 bulk aggregation increased in the presence of laurate but not oleate salts. Both salt types increased the melting temperature of mAb1 indicating FFA-mAb1 interactions. However, only laurate salt increased mAb1 self-association potentially explaining the higher aggregation propensity in its presence. CONCLUSION: Our results help explain the observed differences between hydrolytically degraded PS20 and PS80 in affecting mAb1 aggregation under IV bag agitation conditions.

Evaluating a Modified High Purity Polysorbate 20 Designed to Reduce the Risk of Free Fatty Acid Particle Formation.

PURPOSE: To evaluate a modified high purity polysorbate 20 (RO HP PS20)-with lower levels of stearate, palmitate and myristate esters than the non-modified HP PS20-as a surfactant in biopharmaceutical drug products (DP). RO HP PS20 was designed to provide functional equivalence as a surfactant while delaying the onset of free fatty acid (FFA) particle formation upon hydrolytic degradation relative to HP PS20. METHODS: Analytical characterization of RO HP PS20 raw material included fatty acid ester (FAE) distribution, higher order ester (HOE) fraction, FFA levels and trace metals. Functional assessments included 1) vial and intravenous bag agitation; 2) oxidation via a placebo and methionine surrogate study; and 3) hydrolytic PS20 degradation studies to evaluate FFA particle formation with and without metal nucleation. RESULTS: Interfacial protection and oxidation propensity were comparable between the two polysorbates. Upon hydrolytic degradation, FFA particle onset was delayed in RO HP PS20. The delay was more pronounced when HOEs of PS20 were preferentially degraded. Furthermore, the hydrolytic degradants of RO HP PS20 formed fewer particles in the presence of spiked aluminum. CONCLUSION: This work highlights the criticality of having tighter control on long chain FAE levels of PS20 to reduce the occurrence of FFA particle formation upon hydrolytic degradation and lower the variability in its onset. By simultaneously meeting compendial PS20 specifications while narrowing the allowable range for each FAE and shifting its composition towards the shorter carbon chain species, RO HP PS20 provides a promising alternative to HP PS20 for biopharmaceutical DPs.

A Comprehensive Assessment of All-Oleate Polysorbate 80: Free Fatty Acid Particle Formation, Interfacial Protection and Oxidative Degradation.

PURPOSE: Enzymatic polysorbate (PS) degradation and resulting free fatty acid (FFA) particles are detrimental to biopharmaceutical drug product (DP) stability. Different types and grades of polysorbate have varying propensity to form FFA particles. This work evaluates the homogenous all-oleate (AO) PS80 alongside heterogeneous PS20 and PS80 grades in terms its propensity to form FFA particles and other important attributes like interfacial protection and oxidation susceptibility. METHODS: FFA particle formation rates were compared by degrading PS using non-immobilized hydrolases and fast degrading DP formulations. Interfacial protection of monoclonal antibodies (mAbs) was assessed by agitation studies in saline using non-degraded and degraded PS. Several antioxidants were assessed for their ability to mitigate AO PS80 oxidation and subsequent mAb oxidation by a 40°C placebo stability study and a 2, 2'-Azobis (2-amidinopropane) dihydrochloride stress model, respectively. RESULTS: Visible and subvisible particles were significantly delayed in AO PS80 formulations compared with heterogeneous PS20 and PS80 formulations. Non-degraded AO PS80 was less protective of mAbs against the air-water interface compared with heterogeneous PS20. Interfacial protection by AO PS80 improved upon degradation owing to high surface activity of FFAs. Diethylenetriaminepentaacetic acid (DTPA) completely mitigated AO PS80 oxidation unlike L-methionine and N-Acetyl-DL-Tryptophan. However, DTPA did not mitigate radical mediated mAb oxidation. CONCLUSION: AO PS80 is a promising alternative to reduce FFA particle formation compared with other PS types and grades. However, limitations observed here---such as lower protection against interfacial stresses and higher propensity for oxidation---need to be considered in assessing the risk/benefit ratio in using AO PS80.

Child Care Sites Participating in the Federal Child and Adult Care Food Program Provide More Nutritious Foods and Beverages.

OBJECTIVE: To compare food/beverage provisions between child care sites participating and not participating in the Child and Adult Care Food Program (CACFP). DESIGN: Cross-sectional survey administered in 2016. SETTING: Licensed child care centers and homes. PARTICIPANTS: Child care providers (n = 2,400) randomly selected from California databases (30% responded). Respondents (n = 680) were primarily site directors (89%) at child care centers (83%) participating in CACFP (70%). MAIN OUTCOME MEASURES: Meals/snacks served, and food/beverage provisions provided to children of age 1-5 years on the day before the survey. ANALYSIS: Odds ratios unadjusted and adjusted for the number of meals/snacks using logistic regression. RESULTS: Compared with CACFP sites, non-CACFP sites provided fewer meals/snacks; had lower odds of providing vegetables, meats/poultry/fish, eggs, whole grains, and milk; and had higher odds of providing candy, salty snacks, and sugary drinks. After adjusting for the number of meals/snacks, differences were attenuated but remained significant for meats/poultry/fish, milk, candy, salty snacks (centers only), and sugary drinks. Differences emerged in favor of CACFP for flavored/sugar-added yogurt, sweet cereals, frozen treats, and white grains. CONCLUSIONS AND IMPLICATIONS: Child care sites participating in CACFP are more likely to provide nutritious foods/beverages compared with non-CACFP sites. Child care sites are encouraged to participate in or follow CACFP program guidelines.

Androgen deficiency in long-term intrathecal opioid administration.

BACKGROUND: Intrathecal drug delivery of opioids is an efficient and effective treatment option for pain management in the chronic nonmalignant pain population. As with all treatments, in addition to the benefits, risks and side effects exist. One such risk in intrathecal opioids is opioid-induced androgen deficiency. OBJECTIVE: This study evaluates opioid-induced androgen deficiency in long-term intrathecal opioid administration in chronic nonmalignant pain. STUDY DESIGN: Case series. Sixteen consecutive patients with intrathecal drug delivery with opioids were screened for androgen deficiency. SETTING: Academic university-based pain management center. METHOD: All the subjects were seen in a 2 month period, during a scheduled maintenance refill visit. Eight consecutive men and eight consecutive women receiving intrathecal drug delivery therapy for non-malignant chronic pain were ordered blood work and asked to complete a questionnaire. Patient and patient-related data were also collected. RESULTS: Ten of the 16 (62.5%) patients were found to have androgen deficiency, 4 of 8 men based on free testosterone levels and 6 of 8 women based on DHEA levels. In men, erectile dysfunction correlated with endocrine dysfunction (P = 0.02) while depressive symptoms correlated in women (P = .03). Overall, 2 of the 16 patients had hydromorphone as the opioid in the intrathecal system. Both patients had normal endocrine functions. Both patients with hydromorphone were men and the use of hydromorphone showed an insignificant trend (P = 0.06). Three of the 4 men with normal endocrine functions had in addition to an opioid, bupivacaine, in the intrathecal system. The presence of bupivicaine in men was significant (P = 0.02). No women had bupivicaine while one of the 8 women had clonidine in addition to the opioid. Presence of another substance in addition to the opioid showed an insignificant trend (P = 0.08). LIMITATIONS: Study limitations include the small sample size and case series nature. Additionally the symptoms data was solely based on subjective patient reports. CONCLUSIONS: Androgen deficiency is common in patients treated with intrathecal opioids for chronic nonmalignant pain. Patients experience numerous and wide ranging symptoms. Erectile dysfunction may be more suggestive for androgen deficiency in men while complaints of depressed mood may be correlative in women. Additionally, combining bupivicaine with the intrathecal opioid may provide a protective role.