Novel Organism Verification and Analysis (NOVA) study: identification of 35 clinical isolates representing potentially novel bacterial taxa using a pipeline based on whole genome sequencing.

BACKGROUND: Reliable species identification of cultured isolates is essential in clinical bacteriology. We established a new study algorithm named NOVA - Novel Organism Verification and Analysis to systematically analyze bacterial isolates that cannot be characterized by conventional identification procedures MALDI-TOF MS and partial 16 S rRNA gene sequencing using Whole Genome Sequencing (WGS). RESULTS: We identified a total of 35 bacterial strains that represent potentially novel species. Corynebacterium sp. (n = 6) and Schaalia sp. (n = 5) were the predominant genera. Two strains each were identified within the genera Anaerococcus, Clostridium, Desulfovibrio, and Peptoniphilus, and one new species was detected within Citrobacter, Dermabacter, Helcococcus, Lancefieldella, Neisseria, Ochrobactrum (Brucella), Paenibacillus, Pantoea, Porphyromonas, Pseudoclavibacter, Pseudomonas, Psychrobacter, Pusillimonas, Rothia, Sneathia, and Tessaracoccus. Twenty-seven of 35 strains were isolated from deep tissue specimens or blood cultures. Seven out of 35 isolated strains identified were clinically relevant. In addition, 26 bacterial strains that could only be identified at the species level using WGS analysis, were mainly organisms that have been identified/classified very recently. CONCLUSION: Our new algorithm proved to be a powerful tool for detection and identification of novel bacterial organisms. Publicly available clinical and genomic data may help to better understand their clinical and ecological role. Our identification of 35 novel strains, 7 of which appear to be clinically relevant, shows the wide range of undescribed pathogens yet to define.

Comparison between incus short process and long process coupling of the vibrant soundbridge in human temporal bones.

OBJECTIVE: The Vibrant Soundbridge (VSB) is one of the most widely used implantable hearing devices. It consists of a vibrating floating mass transducer (FMT) that is connected to a middle ear structure. The standard coupling devices for sensorineural hearing loss are short process (SP) or long process (LP) couplers. DESIGN AND STUDY SAMPLE: This study directly compared the electro-mechanical performance of the SP- and LP-coupled FMT of the VSB in the same temporal bone specimen (n = 10). We measured velocity magnitudes and total harmonic distortions (THD) of the stapes (ST) and the round window (RW) using laser Doppler Vibrometry (LDV). RESULTS: Comparison shows a maximally 10 dB higher magnitude for the LP coupler at ST and RW for frequencies below 600 Hz, whereas the SP coupler shows a maximally 20 dB higher magnitude at the ST and RW for frequencies above 600 Hz. THD show similar behaviour with less distortion at 500 Hz for the LP coupler and less distortions for the SP coupler in higher frequencies. CONCLUSIONS: Our experiments showed that the SP coupling may be mechanically favourable, in terms of magnitude and distortion, for the transmission of FMT vibrations at higher frequencies.

A universal anti-Xa assay for rivaroxaban, apixaban, and edoxaban measurements: method validation, diagnostic accuracy and external validation.

A universal anti-Xa assay for the determination of rivaroxaban, apixaban and edoxaban drug concentrations would simplify laboratory procedures and facilitate widespread implementation. Following two pilot studies analysing spiked samples and material from 698 patients, we conducted a prospective multicentre cross-sectional study, including 867 patients treated with rivaroxaban, apixaban or edoxaban in clinical practice to comprehensively evaluate a simple, readily available anti-Xa assay that would accurately measure drug concentrations and correctly predict relevant levels in clinical practice. Anti-Xa activity was measured by an assay calibrated with low-molecular-weight heparin (LMWH) in addition to ultra-high performance liquid chromatography-tandem mass spectrometry (LC-MS/MS). As an external validation, LMWH-calibrated anti-Xa activity was also determined in nine external laboratories. The LMWH-calibrated anti-Xa activity correlated strongly with rivaroxaban, apixaban or edoxaban drug levels [rs  = 0·98, 95% confidence interval (CI) 0·98-0·98]. The sensitivity for the clinically relevant cut-off levels of 30, 50 and 100 µg/l was 96·2% (95% CI 94·4-97·4), 96·4% (95% CI 94·4-97·7) and 96·7% (95% CI 94·3-98·1) respectively. Concordant results were obtained in the external validation study. In conclusion, a universal, LMWH-calibrated anti-Xa assay accurately measured rivaroxaban, apixaban and edoxaban concentrations and correctly predicted relevant drug concentrations in clinical practice.

Gulosibacter hominis sp. nov.: a novel human microbiome bacterium that may cause opportunistic infections.

We present genomic, phylogenomic, and phenotypic taxonomic data to demonstrate that three human ear isolates represent a novel species within the genus Gulosibacter. These isolates could not be identified reliably using MALDI-TOF mass spectrometry during routine diagnostic work, but partial 16S rRNA gene sequence analysis revealed that they belonged to the genus Gulosibacter. Overall genomic relatedness indices between the draft genome sequences of the three isolates and of the type strains of established Gulosibacter species confirmed that the three isolates represented a single novel Gulosibacter species. A biochemical characterisation yielded differential tests between the novel and established Gulosibacter species, which could also be differentiated using MALDI-TOF mass spectrometry. We propose to formally classify these three isolates into Gulosibacter hominis sp. nov., with 401352-2018 T (= LMG 31778 T, CCUG 74795 T) as the type strain. The whole-genome sequence of strain 401352-2018 T has a size of 2,340,181 bp and a G+C content of 62.04 mol%. A Gulosibacter pangenome analysis revealed 467 gene clusters that were exclusively present in G. hominis genomes. While these G. hominis specific gene clusters were enriched in several COG functional categories, this analysis did not reveal functions that suggested a role in the human microbiome, nor did it explain the occurrence of G. hominis in ear infections. The absence of acquired antimicrobial resistance determinants and virulence factors in the G. hominis genomes, and an analysis of publicly available 16S rRNA gene sequences and 16S rRNA amplicon sequencing data sets suggested that G. hominis is a member of the human skin microbiota that may occasionally be involved in opportunistic infections.

[Emergency treatment of severe bleeding in immune thrombocytopenia]. / Management des blutenden Patienten mit Immunthrombozytopenie.

Immune thrombozytopenia (ITP) is a rare acquired thrombocytopenia occurring in 2 to 4 persons per 100,000 per year. ITP is defined as a platelet count less than 100 G/l in patients in whom other causes of thrombocytopenia have been ruled out. Severe bleeding is rare but may constitute a life-threatening condition. Therapeutic options include platelet transfusions, glucocorticoids and intravenous immune globuline (IVIG). Emergency splenectomy has to be considered in otherwise untreatable bleeding. We present the case of a 65-year-old patient with chronic refractory ITP and finally fatal bleeding.

Searching for New Physics in Two-Neutrino Double Beta Decay.

Motivated by nonzero neutrino masses and the possibility of new physics discovery, a number of experiments search for neutrinoless double beta decay. While hunting for this hypothetical nuclear process, a significant amount of two-neutrino double beta decay data have become available. Although these events are regarded and studied mostly as the background of neutrinoless double beta decay, they can also be used to probe physics beyond the standard model. In this Letter, we show how the presence of right-handed leptonic currents would affect the energy distribution and angular correlation of the outgoing electrons in two-neutrino double beta decay. Consequently, we estimate constraints imposed by currently available data on the existence of right-handed neutrino interactions without having to assume their nature. In this way, our results complement the bounds coming from the nonobservation of neutrinoless double beta decay as they limit also the exotic interactions of Dirac neutrinos. We perform a detailed calculation of two-neutrino double beta decay under the presence of exotic (axial-) vector currents, and we demonstrate that current experimental searches can be competitive to existing limits.

Functional improvement is sustained following anatomical and reverse shoulder arthroplasty for fracture sequelae: a registry-based analysis.

INTRODUCTION: Shoulder arthroplasty for proximal humerus fracture sequelae is known to provide significant patient improvement, yet this outcome varies with time, prosthesis type, and fracture sequelae. We outline the expected course of postoperative shoulder pain and function in patients with anatomical (ASA) or reverse (RSA) shoulder arthroplasty following different fracture sequelae. MATERIALS AND METHODS: Of 111 consecutive patients from our local shoulder arthroplasty registry, 32 underwent ASA for Boileau type 1 sequelae and 77 RSA patients were identified with Boileau types I, III, and IV. By 5 year post-surgery, there were 72 patients available. All patients underwent standardised ASA or RSA procedures with anatomical (Promos Standard; Lima SMR™; Arthrex Eclipse™; Univers™ II) or reverse prostheses (Promos Reverse®; Lima SMR™ Reverse; Univers Revers™; Aequalis® Reversed). Range of motion, Constant-Murley, Disability of the Arm, Shoulder and Hand (DASH), and Shoulder Pain and Disability Index (SPADI) scores were compared at 6, 12, 24, and 60 months postoperatively. We used generalised linear mixed models or random-effects ordered logistic regression to investigate postoperative changes of outcome parameters from baseline to follow-up time points for each group as well as for group comparisons. RESULTS: Range of motion and clinical scores improved until 24 months postoperatively and did not deteriorate thereafter, except for internal rotation of Boileau type III and IV patients and external rotation of RSA patients with type I and IV sequelae. At all follow-ups, ASA patients with Boileau type I sequelae had significantly better internal and external rotation versus patients with RSA and/or other Boileau types (p < 0.001), while Constant, DASH, and SPADI scores were not significantly different between groups. CONCLUSION: In humeral fracture sequelae, ASA and RSA lead to sustained clinical improvements. Surgeons may primarily consider implantation of ASA in type I sequelae.

Coronary angiography with or without percutaneous coronary intervention in patients with hemophilia-Systematic review.

OBJECTIVES: We aimed to summarize the evidence for periprocedural and long-term strategies to both minimize the bleeding risk and ensure sufficient anticoagulation and antiaggregation in hemophilia patients undergoing coronary angiography with or without percutaneous coronary interventions (PCI). BACKGROUND: Hemophilia patients undergoing coronary angiography and PCI are at risk of bleeding due to deficiency of the essential clotting factors VIII or IX combined with the need of peri-interventional anticoagulation and antiaggregation and dual antiplatelet therapy (DAPT) after PCI. METHODS: We report on a patient with moderate hemophilia B undergoing single-vessel PCI with administration of factor IX concentrate during the procedure and during the 1-month DAPT period. In addition, a systematic review of patients (n = 54, mean age 58 ± 10 years) with hemophilia A (n = 45, 83%) or B (n = 9, 17%) undergoing coronary angiography with or without PCI is presented. RESULTS: Peri-interventional factor substitution was performed in the majority (42 of 54, 78%) but not all patients. In 38 of 54 (70%) patients undergoing coronary angiography, PCI with balloon dilation (n = 5), bare metal (n = 31), or drug-eluting stents (n = 2) was performed. For PCI unfractioned heparin (n = 24), low molecular weight heparin (n = 2), bivalirudin (n = 4), or no periprocedural anticoagulation at all (n = 8) were used. PCI was successful in all cases. After stenting, the majority (28 of 33; 85%) was treated with DAPT (median duration 1 month). Major periprocedural bleeding episodes occurred in 3 of 54 (6%) patients. Bleeding during follow-up occurred in 11 of 54 (20%) patients. CONCLUSIONS: Coronary angiography and PCI in patients with hemophilia are effective and safe when applying individualized measures to prevent bleeding.

Extended Half-Life Factor VIII and Factor IX Preparations.

In the last couple of years, several extended half-life factor VIII and factor IX preparations were intensively studied and gained approval. In order to extend half-lives, techniques like fusion to protein conjugates (Fc part of IgG1 or albumin), chemical modification (PEGylation), and protein sequence modification are implemented. With these techniques, it is possible to extend half-lives of factor IX products 4- to 6- fold, while half-life extension of factor VIII products is limited to 1.5- to 2-fold due to their interaction with von Willebrand factor. Nevertheless, both extended half-life factor VIII and IX products have improved and facilitated prophylactic factor replacement therapy in hemophilia A and B, respectively. Extended half-life factor concentrates pose challenges to coagulation laboratories because accurate therapy monitoring is not possible with all factor activity assays currently used.

The Potential Close Future of Hemophilia Treatment - Gene Therapy, TFPI Inhibition, Antithrombin Silencing, and Mimicking Factor VIII with an Engineered Antibody.

Summary Hemophilia is one of the best researched monogenic diseases. Hemophilia A will affect approximately 1:5,000 male live births. In recent decades, great progress has been made with the introduction of recombinant proteins in the 1990s for therapy and prophylaxis, securing adequate availability and, with the introduction of the prophylaxis concept, reducing the negative impact of hemophilia on morbidity (especially arthropathy). Despite this progress, there are still challenges to overcome to secure adequate prophylaxis and treatment: for the time being, causal pharmacological hemophilia prophylaxis and therapy requires repeated i.v. application on a regular basis. Although this approach leads to a reduced comorbidity, it does not yet represent an optimized approach with continuous reversal of the hemophilic defect, which would be the ideal solution. This review summarizes the very new treatment strategies for the treatment of hemophilia A and B.

[Direct oral anticoagulants and drug-drug interactions]. / Direkte orale Antikoagulantien und Medikamenteninteraktionen.

Vitamin K antagonists (VKA) top the list of drugs with most drug and dietary interactions and they are among the medications with the highest incidence of life-threatening events. The new direct oral anticoagulants (DOACs) have been developed to overcome many of the disadvantages of a VKA therapy. Especially, fewer clinically significant drug interactions have been reported to date. However, a number of interactions must be considered. These interactions are linked to the DOAC's specific metabolic pathways. The results of these interactions are changes of the DOAC plasma levels leading either to a higher bleeding risk or to a lower therapeutic efficacy. It is known that patients on VKA and on concomitant polymedication show a higher risk of bleeding. Polymedication is more often found in elderly patients. Patients in this population also have more often an indication for an anticoagulant therapy. Various medications are known to lead to an impaired platelet function. An increase of the bleeding risk in case of a platelet function disorder when additionally taking a DOAC is very likely. Therefore, careful consideration of side effects of both DOAC and concomitant medication when prescribing an anticoagulant therapy is mandatory.

Cryopreserved stem cell products containing dimethyl sulfoxide lead to activation of the coagulation system without any impact on engraftment.

BACKGROUND: Dimethyl sulfoxide (DMSO) is extensively used as a cryoprotectant in stem cell preservation. Little is known on direct hemostatic changes in recipients of hematopoietic stem cell transplantation (HSCT), immediately after DMSO administration. The objectives of the current study were to measure hemostatic changes during HSCT. STUDY DESIGN AND METHODS: In this prospective analysis, changes in plasma biomarkers, platelets (PLTs), or endothelial cells (D-dimers, thrombin-antithrombin complex [TAT], microparticle activity as thrombin-generation potential [MPA], whole blood aggregation, von Willebrand factor) were measured before and immediately after HSCT. Furthermore, associations with clinical complications were recorded. RESULTS: A total of 54 patients were included in the study. Mean MPA and TAT increased significantly immediately after HSCT, returning to baseline the day after the procedure (p<0.01). No significant differences in engraftment for neutrophils and PLTs were found in patients presenting a high increase of TAT or MPA compared with those presenting with a smaller increase. Patients with a high increase in TAT and MPA had received a greater number of total mononucleated cells (p<0.001) and higher transplant volumes (p=0.002). CONCLUSIONS: Infusion of stem cells containing DMSO reversibly activated coagulation, measured as thrombin generation. This finding was not associated with acute adverse events and did not influence engraftment. Further studies are needed to compare variable DMSO concentrations as well as DMSO-free products, to better address the influence of DMSO on hemostasis.

An Implantable Piezofilm Middle Ear Microphone: Performance in Human Cadaveric Temporal Bones.

PURPOSE: One of the major reasons that totally implantable cochlear microphones are not readily available is the lack of good implantable microphones. An implantable microphone has the potential to provide a range of benefits over external microphones for cochlear implant users including the filtering ability of the outer ear, cosmetics, and usability in all situations. This paper presents results from experiments in human cadaveric ears of a piezofilm microphone concept under development as a possible component of a future implantable microphone system for use with cochlear implants. This microphone is referred to here as a drum microphone (DrumMic) that senses the robust and predictable motion of the umbo, the tip of the malleus. METHODS: The performance was measured by five DrumMics inserted in four different human cadaveric temporal bones. Sensitivity, linearity, bandwidth, and equivalent input noise were measured during these experiments using a sound stimulus and measurement setup. RESULTS: The sensitivity of the DrumMics was found to be tightly clustered across different microphones and ears despite differences in umbo and middle ear anatomy. The DrumMics were shown to behave linearly across a large dynamic range (46 dB SPL to 100 dB SPL) across a wide bandwidth (100 Hz to 8 kHz). The equivalent input noise (over a bandwidth of 0.1-10 kHz) of the DrumMic and amplifier referenced to the ear canal was measured to be about 54 dB SPL in the temporal bone experiment and estimated to be 46 dB SPL after accounting for the pressure gain of the outer ear. CONCLUSION: The results demonstrate that the DrumMic behaves robustly across ears and fabrication. The equivalent input noise performance (related to the lowest level of sound measurable) was shown to approach that of commercial hearing aid microphones. To advance this demonstration of the DrumMic concept to a future prototype implantable in humans, work on encapsulation, biocompatibility, and connectorization will be required.

Proteomic profiling for biomarker discovery in heparin-induced thrombocytopenia.

ABSTRACT: New analytical techniques can assess hundreds of proteins simultaneously with high sensitivity, facilitating the observation of their complex interplay and role in disease mechanisms. We hypothesized that proteomic profiling targeting proteins involved in thrombus formation, inflammation, and the immune response would identify potentially new biomarkers for heparin-induced thrombocytopenia (HIT). Four existing panels of the Olink proximity extension assay covering 356 proteins involved in thrombus formation, inflammation, and immune response were applied to randomly selected patients with suspected HIT (confirmed HIT, n = 32; HIT ruled out, n = 38; and positive heparin/platelet factor 4 [H/PF4] antibodies, n = 28). The relative difference in protein concentration was analyzed using a linear regression model adjusted for sex and age. To confirm the test results, soluble P-selectin was determined using enzyme-linked immunosorbent assay (ELISA) in above mentioned patients and an additional second data set (n = 49). HIT was defined as a positive heparin-induced platelet activation assay (washed platelet assay). Among 98 patients of the primary data set, the median 4Ts score was 5 in patients with HIT, 4 in patients with positive H/PF4 antibodies, and 3 in patients without HIT. The median optical density of a polyspecific H/PF4 ELISA were 3.0, 0.9, and 0.3. Soluble P-selectin remained statistically significant after multiple test adjustments. The area under the receiver operating characteristic curve was 0.81 for Olink and 0.8 for ELISA. Future studies shall assess the diagnostic and prognostic value of soluble P-selectin in the management of HIT.

Accuracy of Diagnosing Heparin-Induced Thrombocytopenia.

Importance: Heparin-induced thrombocytopenia (HIT) is a life-threatening condition that requires urgent diagnostic clarification. However, knowledge of the diagnostic utility of the recommended diagnostic tests is limited in clinical practice. Objective: To evaluate the current diagnostic practice for managing the suspicion of HIT. Design, Setting, and Participants: This prospective diagnostic study was conducted from January 2018 to May 2021 among consecutive patients with suspected HIT from 11 study centers in Switzerland, Germany, and the United States. Detailed clinical data and laboratory information were recorded. Platelet factor 4/heparin antibodies were quantified using an automated chemiluminescent immunoassay (CLIA). A washed-platelet heparin-induced platelet activation (HIPA) test was used as a reference standard to define HIT. Exposures: Suspicion of HIT. Main Outcomes and Measures: The primary outcome was the diagnostic accuracy of the 4Ts score, the CLIA, and the recommended algorithm serially combining both tests. Results: Of 1448 patients included between 2018 and 2021, 1318 were available for the current analysis (median [IQR] age, 67 [57-75] years; 849 [64.6%] male). HIPA was positive in 111 patients (prevalence, 8.4%). The most frequent setting was intensive care unit (487 [37.0%]) or cardiovascular surgery (434 [33.0%]). The 4Ts score was low risk in 625 patients (46.8%). By 2 × 2 table, the numbers of patients with false-negative results were 10 (9.0%; 4Ts score), 5 (4.5%; CLIA), and 15 (13.5%; recommended diagnostic algorithm). The numbers of patients with false-positive results were 592 (49.0%; 4Ts score), 73 (6.0%; CLIA), and 50 (4.1%; recommended diagnostic algorithm), respectively. Conclusions and Relevance: In this diagnostic study of patients suspected of having HIT, when the recommended diagnostic algorithm was used in clinical practice, antibody testing was required in half the patients. A substantial number of patients were, however, still misclassified, which could lead to delayed diagnosis or overtreatment. Development of improved diagnostic algorithms for HIT diagnosis should be pursued.

Human blood-labyrinth barrier on a chip: a unique in vitro tool for investigation of BLB properties.

Hearing loss is one of the leading causes of disability worldwide, usually as a result of hair cell damage in the inner ear due to aging, acoustic trauma, or exposure to antibiotics or chemotherapy. No drug therapies can protect or restore hearing and current in vitro and animal models used in drug discovery have a very low success rate, mostly due to major differences in anatomy and accessibility of the inner ear environment between species. The blood-labyrinth barrier (BLB) in the stria vascularis is a highly specialized capillary network that controls exchanges between the blood and interstitial space in the cochlea. The BLB is critical for normal hearing, functioning as a physical, transport, and metabolic barrier. To address its complexity and accessibility, we created the first micro-engineered human model of BLB on a chip using autogenous progenitor cells from adult temporal bones. We successfully isolated the BLB from post-mortem human tissue and established an endothelial cell and pericyte culture system on a BLB chip. Using biocompatible materials, we fabricated sustainable two chamber chips. We validated the size-dependent permeability limits of our BLB model by measuring the permeability to daptomycin (molecular weight 1.6 kDa) and midazolam (molecular weight 325.78 Da). Daptomycin did not pass through the BLB layer, whereas midazolam readily passed through the BLB in our system. Thus, our BLB-chip mimicked the integrity and permeability of human stria vascularis capillaries. This represents a major step towards establishing a reliable model for the development of hearing loss treatments.

Effect of freezing and embalming of human cadaveric whole head specimens on bone conduction.

BACKGROUND AND AIMS: Conserved specimens do not decay and therefore permit long-term experiments thereby overcoming limited access to fresh (frozen) temporal bones for studies on middle ear mechanics. We used a Thiel conservation method which is mainly based on a watery solution of salts. In contrast to pure Formalin, Thiel conservation aims to preserve the mechanical proprieties of human tissue. The aim of this study is to examine the effect of Thiel conservation on bone conduction in the same specimen before and after conservation. METHODS: Nine ears of five defrosted whole heads were stimulated with a direct, electrically driven, bone anchored hearing system (Baha, Baha SuperPower). The motion produced by bone conduction stimulation was measured with a single point laser Doppler vibrometer (LDV) at the promontory, the ossicular chain, and the round window through a posterior tympanotomy. After the initial experiments, the entire whole heads were placed in Thiel solution. In order to enable direct comparison between fresh frozen and Thiel specimens, our Thiel conservation did not include intravascular and intrathecal perfusion. The measurements were repeated 3 and 12 months later. To determine the effect of freezing, defrosting, and embalming on the whole heads, CT scans were performed at different stages of the experimental procedure. Additionally, three extracted temporal bones were stimulated a Baha, motion of the promontory measured by LDV and embalmed in Thiel solution to investigate the direct impact of Thiel solution on the bone. RESULTS: The averaged magnitude of motion on the promontory increased in whole head specimens by a mean of 10.3 dB after 3 months of Thiel embalming and stayed stable after 12 months. A similar effect was observed for motion at the tympanic membrane (+7.2 dB), the stapes (+9.5 dB), and the round window (+4.0 dB). In contrast to the whole head specimens, the motion of the extracted temporal bones did not change after 3 months of Thiel embalming (-0.04 dB in average). CT scans of the whole heads after conservation showed a notable brain volume loss mostly >50% as well as a remarkable change in the consistency and structure of the brain. Partial changes could already be observed before the Thiel embalming but after 1-2 days of defrosting. In an additional experiment, a substitution of brain mass and weight by Thiel fluid did not lead to new deterioration in sound transmission. In contrast, a frozen (non-defrosted) whole head showed a distinctively reduced magnitude of promontory motion before defrosting. DISCUSSION: For our setup, the vibration of the ear due to bone conduction in the same whole head specimens significantly increased after Thiel conservation. Such an increase was not observed in extracted temporal bone specimens. Due to brain changes in the CT scans, we investigated the consequences of the brain volume changes and structure loss on the frozen brain before defrosting. The loss of brain volume alone could not explain the increase of ear vibrations, as we did not observe a difference when the volume was replaced with Thiel fluid. However, freezing and defrosting of the entire brain seems to have a major influence. Beside the destructive effect of freezing on the brain, the modified conservation method without perfusion changed the brain structure. In conclusion, bone conduction in whole heads depends on the physical condition of the brain, rather than on the conservation.

Limited concordance of heparin/platelet factor 4 antibody assays for the diagnosis of heparin-induced thrombocytopenia: an analysis of the TORADI-HIT study.

BACKGROUND: Anecdotal reports suggest that the correlation between heparin/platelet factor 4 (PF4) antibody assays for the diagnosis of heparin-induced thrombocytopenia (HIT) is limited. OBJECTIVES: To investigate the correlation between widely used assays and examine possible factors contributing to variability. METHODS: This is a large, prospective cohort study with 10 participating tertiary care hospitals including 1393 patients with suspected HIT in clinical practice. HIT was defined by a positive heparin-induced platelet activation (HIPA) assay (washed platelet reference standard test). Three different immunoassays were used to measure heparin/PF4 antibodies: chemiluminescent immunoassay, enzyme-linked immunosorbent assay, and particle gel immunoassay. Various factors that could influence the assays were examined: sex (male or female), age (<65 years or ≥65 years), unfractionated heparin exposure, presence of thrombosis, cardiovascular surgery, and intensive care unit. Spearman's correlation coefficients were calculated. Z-scores and diagnostic odds ratios were determined in the aforementioned subgroups of patients. RESULTS: Among 1393 patients, 119 were classified as HIT-positive (prevalence, 8.5%). The median 4Ts score was 5 (IQR, 4-6) in patients with HIT compared with 3 (IQR, 2-4) in patients without HIT. Correlations (rs) between immunoassays were weak (0.53-0.65). Inconsistencies between immunoassays could not be explained by further analyses of z-scored test results and diagnostic odds ratios in subgroups of patients. CONCLUSION: The correlation between widely used heparin/PF4 antibody assays was weak, and key factors could not explain this variability. Standardization of immunoassays is requested to improve comparability.

Determination of Anti-Xa Inhibitor Plasma Concentrations Using a Universal Edoxaban Calibrator.

A universal calibrator for the determination of all anti-Xa inhibitors would support laboratory processes. We aimed to test the clinical performance of an anti-Xa assay utilizing a universal edoxaban calibrator to determine clinically relevant concentrations of all anti-Xa inhibitors. Following a pilot study, we enrolled 553 consecutive patients taking rivaroxaban, edoxaban, or apixaban from nine study centers in a prospective cross-sectional study. The Technochrom® anti-Xa assay was conducted using the Technoview® edoxaban calibrator. Using ultra-high-performance liquid chromatography-tandem mass spectrometry (LC-MS/MS), anti-Xa inhibitor drug concentrations were determined. Sensitivities and specificities to detect three clinically relevant drug concentrations (30 µgL-1, 50 µgL-1, 100 µgL-1) were determined. Overall, 300 patients treated with rivaroxaban, 221 with apixaban, and 32 with edoxaban were included. The overall correlation coefficient (rs) was 0.95 (95% CI 0.94, 0.96). An area under the receiver operating characteristic curve of 0.96 for 30 µgL-1, 0.98 for 50 µgL-1, and 0.99 for 100 µgL-1 was found. The sensitivities were 92.3% (95% CI 89.2, 94.6), 92.7% (89.4, 95.1), and 94.8% (91.1, 97.0), respectively (specificities 82.2%, 93.7%, and 94.4%). In conclusion, the clinical performance of a universal, edoxaban-calibrated anti-Xa assay was solid and most drug concentrations were predicted correctly.