Mirikizumab as Induction and Maintenance Therapy for Ulcerative Colitis.

BACKGROUND: Mirikizumab, a p19-directed antibody against interleukin-23, showed efficacy in the treatment of ulcerative colitis in a phase 2 trial. METHODS: We conducted two phase 3, randomized, double-blind, placebo-controlled trials of mirikizumab in adults with moderately to severely active ulcerative colitis. In the induction trial, patients were randomly assigned in a 3:1 ratio to receive mirikizumab (300 mg) or placebo, administered intravenously, every 4 weeks for 12 weeks. In the maintenance trial, patients with a response to mirikizumab induction therapy were randomly assigned in a 2:1 ratio to receive mirikizumab (200 mg) or placebo, administered subcutaneously, every 4 weeks for 40 weeks. The primary end points were clinical remission at week 12 in the induction trial and at week 40 (at 52 weeks overall) in the maintenance trial. Major secondary end points included clinical response, endoscopic remission, and improvement in bowel-movement urgency. Patients who did not have a response in the induction trial were allowed to receive open-label mirikizumab during the first 12 weeks of the maintenance trial as extended induction. Safety was also assessed. RESULTS: A total of 1281 patients underwent randomization in the induction trial, and 544 patients with a response to mirikizumab underwent randomization again in the maintenance trial. Significantly higher percentages of patients in the mirikizumab group than in the placebo group had clinical remission at week 12 of the induction trial (24.2% vs. 13.3%, P<0.001) and at week 40 of the maintenance trial (49.9% vs. 25.1%, P<0.001). The criteria for all the major secondary end points were met in both trials. Adverse events of nasopharyngitis and arthralgia were reported more frequently with mirikizumab than with placebo. Among the 1217 patients treated with mirikizumab during the controlled and uncontrolled periods (including the open-label extension and maintenance periods) in the two trials, 15 had an opportunistic infection (including 6 with herpes zoster infection) and 8 had cancer (including 3 with colorectal cancer). Among the patients who received placebo in the induction trial, 1 had herpes zoster infection and none had cancer. CONCLUSIONS: Mirikizumab was more effective than placebo in inducing and maintaining clinical remission in patients with moderately to severely active ulcerative colitis. Opportunistic infection or cancer occurred in a small number of patients treated with mirikizumab. (Funded by Eli Lilly; LUCENT-1 and LUCENT-2 ClinicalTrials.gov numbers, NCT03518086 and NCT03524092, respectively.).

Incidência e eventos adversos da hipodermóclise no idoso em cuidados paliativos / Incidencia y eventos adversos de hipodermoclisis en ancianos en cuidados paliativos / Incidence and adverse events of hypodermoclysis in the elderly in palliative care

Objetivo: estimar a incidência, tempo de ocorrência de eventos adversos e tempo de permanência da hipodermóclise no idoso Método: Pesquisa realizada com 127 idosos em cuidados paliativos. A avaliação da hipodermóclise foi realizada a cada 24 horas até a ocorrência do evento. Realizou-se análise descritiva, calculando as proporções e a taxa de incidência por 100 punções/pacientes. Resultados: A taxa de incidência dos eventos adversos foi de 22,8% para a hipodermóclise e 27% para os indivíduos em uso de hipodermóclise. O cateter permaneceu em média quatro dias, sendo no mínimo um dia e no máximo 15 dias; a chance de eventos adversos no primeiro dia foi de 6%, de 28% no quinto dia e 48% no décimo. Conclusão: Incidência de eventos adversos foi pequena e localizada; tempo médio da permanência do cateter no local de inserção foi de quatro dias e as probabilidades de apresentar complicações aumentaram no decorrer dos dias.

Objective: to estimate the incidence, time of occurrence of adverse events and time of permanence of hypodermoclysis in the elderly. Method: Research carried out with 127 elderly people in Palliative Care. Assessment of hypodermoclysis was performed every 24 hours until the event occurred. Descriptive analysis was performed, proportions and incidence rate were calculated per 100 punctures/patients. Results: The incidence rate of adverse events was 22.8% for hypodermoclysis and 27% for individuals using hypodermoclysis. The catheter remained for an average of 4 days, with a minimum of 1 day and a maximum of 15 days; the chance of adverse events on the 1st day was 6%, 28% on the 5th day and 48% on the 10th. Conclusion: The incidence of adverse events was small and localized; mean time of catheter permanence at the insertion site was 4 days and the probability of presenting complications increased over the days.

Objetivo: estimar la incidencia, tiempo de ocurrencia de eventos adversos y tiempo de permanencia de la hipodermoclisis en ancianos Método: Investigación realizada con 127 ancianos en Cuidados Paliativos. La evaluaciónde la hipodermoclisis se realizó cada 24 horas hasta que ocurrió el evento. Se realizó análisis descriptivo, se calcularon proporciones y tasa de incidencia por 100 punciones/pacientes. Resultados: La tasa de incidencia de eventos adversos fue del 22,8 % para la hipodermoclisis y del 27 % para los individuos que usaban la hipodermoclisis. El catéter permaneció en promedio 4 días, con un mínimo de 1 día y un máximo de 15 días; la probabilidad de eventos adversos el primer día fue del 6 %, del 28 % el quinto día y del 48 % el décimo. Conclusión: La incidencia de eventos adversos fue pequeña y localizada; el tiempo medio de permanencia del catéter en el sitio de inserción fue de 4 días y la probabilidad de presentar complicaciones aumentó con el transcurso de los días.

Mast cell-derived prostaglandin D2 limits the subcutaneous absorption of honey bee venom in mice.

Mast cells play pivotal roles in innate host defenses against venom. Activated mast cells release large amounts of prostaglandin D2 (PGD2). However, the role of PGD2 in such host defense remains unclear. We found that c-kit-dependent and c-kit-independent mast cell-specific hematopoietic prostaglandin D synthase (H-pgds) deficiency significantly exacerbated honey bee venom (BV)-induced hypothermia and increased mortality rates in mice. BV absorption via postcapillary venules in the skin was accelerated upon endothelial barrier disruption resulting in increased plasma venom concentrations. These results suggest that mast cell-derived PGD2 may enhance host defense against BV and save lives by inhibiting BV absorption into circulation.

Development of Drug Release Model for Suspensions in ESCAR (Emulator of SubCutaneous Absorption and Release).

We recently developed an in vitro testing system, namely, ESCAR (Emulator of SubCutaneous Absorption and Release). The objective of this work was to investigate drug release behaviors of unmilled and milled suspensions in ESCAR. A mass transport-based model was developed to describe the multi-step drug release process, including drug dissolution, particle settling, drug distribution/partition, and drug permeation through the membrane(s). To address the particle settling effect, a correction factor was included in the model and its value was obtained by data fitting. It was found that, for both suspensions, (i) the experimental data of various dose/formulation combinations could be fit by the developed model; (ii) the dose effect on drug release was offset by the particle settling effect. This model may help to reduce experimental efforts and facilitate subcutaneous suspension formulation development using ESCAR.

Prediction of subcutaneous drug absorption - Characterization of subcutaneous interstitial fluids as a basis for developing biorelevant in vitro models.

Unlike orally administered drugs, the absorption profile of subcutaneously injectable drugs in humans is difficult to predict from preclinical studies. Since the subcutaneous interstitial fluid (ISF) is the first fluid interacting with the administered formulation before the respective drug is absorbed, it could critically affect bioavailability. The aim of the present study was to gain a better understanding of the similarities and differences of ISF of different species. For this purpose, ISF was isolated from subcutaneous tissues of five preclinical animal species, i.e., mice, rats, minipig, landrace pig, non-human primates, and humans, using a centrifugation method, and characterized with respect to its major constituents and physicochemical properties. The results show trends between animal species, with ISF from non-human primates differing significantly from that of the other preclinical species for most parameters analyzed and showing similarities to ISF of human origin. Although from a statistical point of view it will be necessary to further increase the existing data sets, the presented data provide valuable information for the development of biorelevant in vitro models to predict the in vivo performance of subcutaneously administered formulations, as they provide fundamental information for the design of biorelevant ISF media for both preclinical species and humans.

Physiological based pharmacokinetic and biopharmaceutics modelling of subcutaneously administered compounds - An overview of in silico models.

Subcutaneous injection is a commonly used route of drug administration for both small molecules and biologics. To facilitate the development of new subcutaneously administered drugs, methods for prediction of drug absorption from the injection site are essential. For this purpose, in silico models have increasingly been used. This report summarize the current state of in silico models for description and prediction of subcutaneous drug absorption. Original articles on physiologically based models describing subcutaneous administration published from 2010 and onward were reviewed. Eighteen physiologically based models were identified: eleven for small molecules and seven for biologics. Most models described the PK of one drug and for one species. In models for small molecules, the subcutaneous administration site was most often described as a depot compartment with first-order absorption into the plasma or blood. Most models for biologics divided administration and organ compartments into vascular and interstitial subcompartments. Mass transfer to these compartments was frequently described with convection and diffusion, according to the one- or two-pore theory. Tremendous improvement in the quantitative aspects of subcutaneous administration and subsequent absorption of physiologically based models has occurred the last decade. However, improvements related to data translation and generalization of these models were identified.

Modeling Between-Subject Variability in Subcutaneous Absorption of a Long-Acting Insulin Glargine 100 U/mL by a Nonlinear Mixed Effects Approach.

Subcutaneous insulin absorption is well-known to vary significantly both between and within subjects (BSV and WSV, respectively). This variability considerably obstacles the establishing of a reproducible and effective insulin therapy. Some models exist to describe the subcutaneous kinetics of both fast and long-acting insulin analogues; however, none of them account for the BSV. The aim of this study is to develop a nonlinear mixed effects model able to describe the BSV observed in the subcutaneous absorption of a long-acting insulin glargine 100 U/mL. Four stochastic models of the BSV were added to a previously validated model of subcutaneous absorption of insulin glargine 100 U/mL. These were assessed on a database of 47 subjects with type 1 diabetes. The best model was selected based on residual analysis, precision of the estimates and parsimony criteria. The selected model provided good fit of individual data, precise population parameter estimates and allowed quantifying the BSV of the insulin glargine 100 U/mL pharmacokinetics. Future model development will include the description of the WSV of long- acting insulin absorption.

Multiscale pharmacokinetic modeling of systemic exposure of subcutaneously injected biotherapeutics.

Subcutaneously injected formulations have been developed for many biological products including monoclonal antibodies (mAbs). A knowledge gap nonetheless remains regarding the absorption and catabolism mechanisms and kinetics of a large molecule at the administration site. A multiscale pharmacokinetic (PK) model was thus developed by coupling multiphysics simulations of subcutaneous (SC) absorption kinetics with whole-body pharmacokinetic (PK) modeling, bridged by consideration of the presystemic clearance by the initial lymph. Our local absorption simulation of SC-injected albumin enabled the estimation of its presystemic clearance and led to the whole-body PK modeling of systemic exposure. The local absorption rate of albumin was found to be influential on the PK profile. Additionally, nineteen mAbs were explored via this multiscale simulation and modeling framework. The computational results suggest that stability propensities of the mAbs are correlated with the presystemic clearance, and electrostatic charges in the complementarity-determining region influence the local absorption rate. Still, this study underscores a critical need to experimentally determine various biophysical characteristics of a large molecule and the biomechanical properties of human skin tissues.

Dermatological surgery: an update on suture materials and techniques. Part 2.

This is the second part of a two-part series summarizing the latest evidence related to suture materials and wound closure techniques in dermatological surgery. We critically appraised evidence focusing on the following consequences of suture choice: scar/cosmesis, pain, patient satisfaction, cost, infection and wound complications. We searched the databases MEDLINE, PubMed and Embase using the keywords 'skin surgery', 'dermatological surgery', 'sutures', 'braided sutures', 'monofilament sutures' and 'antibacterial sutures' to identify relevant English-language articles. This part of the review assesses the evidence for different types of buried sutures, including braided vs. monofilament sutures, longer-absorbing sutures and antibacterial sutures. The majority of trials were noted to be of poor quality, single-centre (thus lacking external validity) and underpowered, which presents challenges in comparing suture techniques in skin surgery. Future large-scale, multicentre, randomized trials are needed, with both surgeon and patient-assessed validated outcomes.

A Two-Pore Physiologically Based Pharmacokinetic Model to Predict Subcutaneously Administered Different-Size Antibody/Antibody Fragments.

Quantitative modeling of the subcutaneous absorption processes of protein therapeutics is challenging. Here we have proposed a "two-pore" PBPK model that is able to simultaneously characterize plasma PK of different-size protein therapeutics in mice. The skin compartment is evolved to mechanistically account for the absorption pathways through lymph and blood capillaries, as well as local degradation at the SC injection site. The model is developed using in-house plasma PK data generated following subcutaneous administration of 6 different-size protein therapeutics (13-150 kDa) in mice. The model was able to capture plasma PK of all molecules following intravenous and subcutaneous administration relatively well. From the observed plasma PK profiles, as well as from the model simulation result, several important PK descriptors were found to be dependent on protein size for FcRn nonbinding molecules. A positive correlation was found between Tmax and protein size. A "U" shape relationship was found between Cmax and protein size. Negative correlations were observed between bioavailability (F) and local degradation rate (kdeg,SC), and F and protein size. Pathway analysis of the model was conducted for the subcutaneous absorption process, and continuous relationships were established between the percentage of absorption through lymphatic and vascular pathways and protein size. This PBPK model could serve as a platform for the development of different-size protein therapeutics and will be scaled up to humans for translational studies in the future.

Population pharmacokinetic model of subcutaneous fentanyl in older acute care patients.

PURPOSE: Subcutaneous fentanyl injection is commonly prescribed to manage acute pain in older patients; however, there is a gap in the literature describing the pharmacokinetic parameters for this route of administration in this population. The aim of this study was to develop and evaluate a population pharmacokinetic model for subcutaneous fentanyl injection in older patients. METHODS: Twenty-one patients who received subcutaneous fentanyl injections (50 to 75 µg) were recruited. Fentanyl concentrations were determined using a validated liquid chromatography/tandem mass spectrometry method. A population pharmacokinetic model was developed using non-linear mixed-effects modelling. A base model was selected based on the Akaike information criterion. Age, sex, body weight, number of previous fentanyl doses, number of prescribed medications, creatinine clearance, Charlson Comorbidity Index, Identification of Seniors at Risk score and concurrent use of CYP3A4 inhibitors were covariates considered for inclusion. A p value of < 0.05 was considered statistically significant for inclusion of covariates in the final model by stepwise addition. The simulation performance of the model was assessed by visual predictive check. RESULTS: A one-compartment, first-order absorption with lag time and linear elimination model was the best to fit to the fentanyl concentration data. The absorption rate constant was 0.136 h-1 (between subject variability (BSV), 46%), lag time 0.66 h (BSV 51%), apparent volume of distribution 6.28 L (BSV 30%), and apparent clearance 16.3 L.h-1 (BSV 54%). The Charlson Comorbidity Index was the only covariate included in the final model, where a higher value of the index increased fentanyl exposure and Cmax. CONCLUSION: This is the first report of subcutaneous fentanyl population pharmacokinetic model to evaluate fentanyl pharmacokinetic in older patients. The between subject variability in clearance and subcutaneous absorption rate was relatively high, and some patients recorded high fentanyl concentrations in the context of their titration to effect.

EFFICACY OF SUBCUTANEOUS IMPLANTS TO PROVIDE CONTINUOUS PLASMA TERBINAFINE IN HELLBENDERS (CRYPTOBRANCHUS ALLEGANIENSI) FOR FUTURE PROPHYLACTIC USE AGAINST CHYTRIDIOMYCOSIS.

Batrachochytrium dendrobatidis (Bd) is an important fungal pathogen present in wild hellbender (Cryptobranchus alleganiensis) populations that appears to cause disease during novel exposure and acute stress. Hellbender repatriation efforts are ongoing to combat declining populations, but mortality by chytridiomycosis (disease from Bd) after release has been reported. The goal was to determine whether a safe antifungal agent could be administered and provide prolonged plasma concentrations without repeated handling. A subcutaneous implant impregnated with 24.5 mg of terbinafine was tested in three juvenile eastern hellbenders (C. a. alleganiensis) raised in human care, and plasma terbinafine concentrations were recorded from weekly to biweekly for 141 days. Plasma concentrations were variable, with peak plasma concentrations of 1,610, 112, and 66 ng/ml between 28 and 56 days postimplant. Although all hellbenders achieved plasma concentrations above the published minimum inhibitory concentration for terbinafine against Bd zoospores (63 ng/ml) at several time points, only one individual remained above this threshold for more than two consecutive time intervals. Results show the potential for these implants as a prophylaxis for chytridiomycosis in captive-to-wild hellbender releases. However, further investigation will be needed to determine the plasma concentrations required to achieve prophylaxis in vivo and implant reliability.

Experimental Solubility, Thermodynamic/Computational Validations, and GastroPlus-Based In Silico Prediction for Subcutaneous Delivery of Rifampicin.

We focused to explore a suitable solvent for rifampicin (RIF) recommended for subcutaneous (sub-Q) delivery [ethylene glycol (EG), propylene glycol (PG), tween 20, polyethylene glycol-400 (PEG400), oleic acid (OA), N-methyl-2-pyrrolidone (NMP), cremophor-EL (CEL), ethyl oleate (EO), methanol, and glycerol] followed by computational validations and in-silico prediction using GastroPlus. The experimental solubility was conducted over temperature ranges T = 298.2-318.2 K) and fixed pressure (p = 0.1 MPa) followed by validation employing computational models (Apelblat, and van't Hoff). Moreover, the HSPiP solubility software provided the Hansen solubility parameters. At T = 318.2K, the estimated maximum solubility (in term of mole fraction) values of the drug were in order of NMP (11.9 × 10-2) ˃ methanol (6.8 × 10-2) ˃ PEG400 (4.8 × 10-2) ˃ tween 20 (3.4 × 10-2). The drug dissolution was endothermic process and entropy driven as evident from "apparent thermodynamic analysis". The activity coefficients confirmed facilitated RIF-NMP interactions for increased solubility among them. Eventually, GastroPlus predicted the impact of critical input parameters on major pharmacokinetics responses after sub-Q delivery as compared to oral delivery. Thus, NMP may be the best solvent for sub-Q delivery of RIF to treat skin tuberculosis (local and systemic) and cutaneous related disease at explored concentration.

Evaluation of epiandrosterone as a long-term marker of testosterone use.

Identification and evaluation of long-term markers is crucial in prolonging the detection window for anabolic steroid abuse in sport. Recently, sulfoconjugated epiandrosterone was identified as a potential long-term marker for the abuse of certain endogenous anabolic agents, including testosterone, which continues to be widely used as a performance enhancing agent in sport. To evaluate the applicability of epiandrosterone sulfate as a marker for testosterone use, administration studies were conducted with multiple modes of testosterone administration - transdermal, intramuscular, and subcutaneous. A modified sample preparation method was used to collect both glucuronidated and sulfoconjugated analytes of interest. Carbon isotope ratio measurements from the administration studies are presented here. Epiandrosterone was less effective than the conventionally used target compounds for detection of the low dose application (transdermal gel). With intramuscular administration, epiandrosterone was more diagnostic than with transdermal administration, but it did not prolong the detection window more than the conventional target compounds. With subcutaneous administration, the doses administered to the subjects were varied and the effect on the epiandrosterone values was dependent on the magnitude of the dose administered. Epiandrosterone does not appear to be a useful marker in the detection of low dose testosterone administration. It is responsive to higher dose administration, but it does not provide an extension of the detection window relative to conventional target compounds.

Influence of physiochemical properties on the subcutaneous absorption and bioavailability of monoclonal antibodies.

Many therapeutic monoclonal antibodies (mAbs) were initially developed for intravenous (IV) administration. As a means to improve mAb drug-ability and the patient experience, subcutaneous (SC) administration is an increasingly important delivery route for mAbs. Unlike IV administration, bioavailability limitations for antibodies have been reported following SC injection and can dictate whether a mAb is administered via this parenteral route. The SC bioavailability of antibodies has been difficult to predict, and it can be variable and partial, with values ranging from ~50% to 100%. The mechanisms leading to the incomplete bioavailability of some mAbs relative to others are not well understood. There are some limited data that suggest the physiochemical properties inherent to a mAb can contribute to its SC absorption, bioavailability, and in vivo fate. In this study, we evaluated the integrated influence of multiple mAb physiochemical factors on the SC absorption and bioavailability of six humanized mAbs in both rats and cynomolgus monkeys. We demonstrate the physiochemical properties of mAbs are critical to their rate and extent of SC absorption. The combination of high positive charge and hydrophobic interaction significantly reduced the rate of the evaluated mAb's SC absorption and bioavailability. Reduction or balancing of both these attributes via re-engineering the mAbs restored desirable properties of the molecules assessed. This included reduced association with SC tissue, improvements in mAb absorption from the SC space and overall SC bioavailability. Our findings point to the importance of evaluating the relative balance between various physiochemical factors, including charge, hydrophobicity, and stability, to improve the SC drug-ability of mAbs for selecting or engineering mAbs with enhanced in vivo absorption and bioavailability following SC administration.

Localized delivery of active targeting micelles from nanofibers patch for effective breast cancer therapy.

Nanofibers based transdermal drug delivery is a promising platform, and it effectively delivers the drug to tumor sites. The objective of the study was to fabricate stimuli-responsive polymeric nanofibers encapsulated with an active targeting micellar system for in situ drug delivery. Stimuli-responsive core-shell nanofibers release thedrug at target sites with minimum side effects to the other organs, decrease the drug administration concentration. Initially, we prepared CA conjugated PCPP polymeric micelles loaded with PTX. Then, core-shell nanofibers were prepared using PHM with coaxial electrospinning and distinct core-shell nanofibers formation confirm by SEM and TEM. Nanofibers showed a homogenous distribution of micelles inside the fiber mesh, diffusion, and erosion processes lead to a controlled release of PTX.In vitro drug release and swelling, revealed the pH based sustained release of the drug for 180 h from the nanofibers mat. Functional and stimuli-responsive nanofibers highly absorb H+ ions and repulsion of cations promoting maximum swelling to release more drugs in acidic pH. An increased transportation rate of 70% drug release through epidermis for 120 h. Nanofibers effectively internalize to the skin, and it confirmed by confocal microscopy. MCF-7 cells grown and spread over the nanofibers, which show the biocompatibility of nanofibers. Compared to PTX, drug-loaded nanofibers exhibited higher cytotoxicity for 8 days which was confirmed by the flow cytometry. These promising results confirm, the novel stimuli-responsive core-shell nanofibers actively target breast cancer cells and lead the way to safe cancer therapy.

Modeling Subcutaneous Absorption of Long-Acting Insulin Glargine in Type 1 Diabetes.

OBJECTIVE: Subcutaneous (sc) administration of long-acting insulin analogs is often employed in multiple daily injection (MDI) therapy of type 1 diabetes (T1D) to cover patient's basal insulin needs. Among these, insulin glargine 100 U/mL (Gla-100) and 300 U/mL (Gla-300) are formulations indicated for once daily sc administration in MDI therapy of T1D. A few semi-mechanistic models of sc absorption of insulin glargine have been proposed in the literature, but were not quantitatively assessed on a large dataset. The aim of this paper is to propose a model of sc absorption of insulin glargine able to describe the data and provide precise model parameters estimates with a clear physiological interpretation. METHODS: Three candidate models were identified on a total of 47 and 77 insulin profiles of T1D subjects receiving a single or repeated sc administration of Gla-100 or Gla-300, respectively. Model comparison and selection were performed on the basis of their ability to describe the data and numerical identifiability. RESULTS: The most parsimonious model is linear two-compartment and accounts for the insulin distribution between the two compartments after sc administration through parameter k. Between the two formulations, we report a lower fraction of insulin in the first versus second compartment (k = 86% versus 94% in Gla-100 versus Gla-300, p < 0.05), a lower dissolution rate from the first to the second compartment ([Formula: see text] versus 0.0008 min-1 in Gla-100 versus Gla-300, p << 0.001), and a similar rate of insulin absorption from the second compartment to plasma ([Formula: see text] versus 0.0016 min-1 in Gla-100 versus Gla-300, p = NS), in accordance with the mechanisms of insulin glargine protraction. CONCLUSIONS: The proposed model is able to both accurately describe plasma insulin data after sc administration and precisely estimate physiologically plausible parameters. SIGNIFICANCE: The model can be incorporated in simulation platforms potentially usable for optimizing basal insulin treatment strategies.

Clinical, Histopathologic, and Immunohistochemical Characterization of Experimental Marburg Virus Infection in A Natural Reservoir Host, the Egyptian Rousette Bat (Rousettus aegyptiacus).

Egyptian rousette bats (Rousettus aegyptiacus) are natural reservoir hosts of Marburg virus (MARV), and Ravn virus (RAVV; collectively called marburgviruses) and have been linked to human cases of Marburg virus disease (MVD). We investigated the clinical and pathologic effects of experimental MARV infection in Egyptian rousettes through a serial euthanasia study and found clear evidence of mild but transient disease. Three groups of nine, captive-born, juvenile male bats were inoculated subcutaneously with 10,000 TCID50 of Marburg virus strain Uganda 371Bat2007, a minimally passaged virus originally isolated from a wild Egyptian rousette. Control bats (n = 3) were mock-inoculated. Three animals per day were euthanized at 3, 5⁻10, 12 and 28 days post-inoculation (DPI); controls were euthanized at 28 DPI. Blood chemistry analyses showed a mild, statistically significant elevation in alanine aminotransferase (ALT) at 3, 6 and 7 DPI. Lymphocyte and monocyte counts were mildly elevated in inoculated bats after 9 DPI. Liver histology revealed small foci of inflammatory infiltrate in infected bats, similar to lesions previously described in wild, naturally-infected bats. Liver lesion severity scores peaked at 7 DPI, and were correlated with both ALT and hepatic viral RNA levels. Immunohistochemical staining detected infrequent viral antigen in liver (3⁻8 DPI, n = 8), spleen (3⁻7 DPI, n = 8), skin (inoculation site; 3⁻12 DPI, n = 20), lymph nodes (3⁻10 DPI, n = 6), and oral submucosa (8⁻9 DPI, n = 2). Viral antigen was present in histiocytes, hepatocytes and mesenchymal cells, and in the liver, antigen staining co-localized with inflammatory foci. These results show the first clear evidence of very mild disease caused by a filovirus in a reservoir bat host and provide support for our experimental model of this virus-reservoir host system.

Intravenous Insulin Infusion Protocol Compared With Subcutaneous Insulin for the Management of Hyperglycemia in Critically Ill Adults.

Background: The use of an intravenous insulin infusion protocol (IIP) is recommended for management of hyperglycemia in the intensive care unit (ICU); however, limited evidence of comparison has been made with subcutaneous (SC) insulin regimens. Objective: This study aims to evaluate the safety and effectiveness of an IIP compared with SC insulin regimens in an ICU patient sample since the implementation of an IIP using a computerized clinical-decision support tool. Methods: This investigation was a retrospective cohort study of patients who were treated for hyperglycemia while admitted to any of the ICUs at a Veterans Affairs Medical Center. Patients who were treated with either an IIP or a scheduled SC insulin regimen between May 1, 2015, and May 25, 2016, were included for evaluation. Results: Blood glucose (BG) was within the normoglycemia range (70-180 mg/dL) for 63.0% of the measurements in patients treated with an IIP (n = 171) compared with 45.7% in those treated with SC insulin regimens (n = 121; P < 0.01). Overall, patients managed with an IIP had a lower proportion of hypoglycemic BG measurements (1.2% vs 2.1%, P < 0.01), a lower proportion of hyperglycemic BG measurements (35.8% vs 52.2%, P < 0.01), and a lower mean BG (172.4 vs 194.3 mg/dL, P < 0.01). Conclusion and Relevance: The results of this study suggest that an IIP in a sample of adult ICU patients was associated with better BG control and lower occurrence of hypoglycemia compared with SC insulin regimens.

The route of Besnoitia besnoiti tachyzoites inoculation does not influence the clinical outcome of the infection in calves.

In a previous attempt, an experimental model of bovine besnoitiosis was established in calves that were intravenously inoculated with different doses of Besnoitia besnoiti tachyzoites. Despite the fact that all infected calves developed the acute stage of disease, only microscopic findings characteristic of chronic besnoitiosis were reported. In the present study, calves were inoculated by subcutaneous and intradermal routes with B. besnoiti tachyzoites with the aim of developing clinical signs and macroscopic lesions characteristic of chronic besnoitiosis. Nine 3-month-old male calves were randomly distributed into three groups of three animals each. Next, 106 tachyzoites were inoculated by either the subcutaneous (G1) or intradermal route (G2). The negative control group (G3) was inoculated with PBS. Daily clinical monitoring and regular blood collection were performed. At 70 days post-infection (pi), animals were euthanized, and tissues were collected to investigate lesions and parasites. Infected animals developed mild-moderate acute besnoitiosis characterized by lymphadenopathy from four days to 47 days pi, and sporadic fever peaks were only observed in one calf from G2. However, other clinical signs and macroscopic lesions characteristic of chronic besnoitiosis were not detected. Only nine tissue samples were B. besnoiti-DNA-positive, eight of which belonged to reproductive and respiratory tracts tissues from G1. Finally, the kinetics of the immune responses were similar in both infected groups. However, delayed and lower cellular and humoral immune responses were observed in G1 followed by G2 and were compared with intravenously inoculated calves. The differences observed among the three inoculation routes could be due to different effector mechanisms of the host early innate immune response against B. besnoiti. Accordingly, the inoculation route of B. besnoiti tachyzoites does not significantly influence the clinical outcome of the infection in calves. Thus, a further refinement of this experimental model of bovine besnoitiosis is needed to reproduce macroscopic lesions characteristic of chronic stage disease.