Search

Tea plantations in Sri Lanka cover the central hills of the island, where spotted fever group (SFG) rickettsial infection is common. In most cases, the history of tick bite is obscure and eschars are not present. A 45-y-old female experienced massive tick bites while working in her tea plantation. She developed fever 2 d after exposure, but the diagnosis of SFG infection was not considered until a skin rash appeared on the eighth day. She had a very high titer of antirickettsial antibodies detected by immunofluorescence assay and responded to doxycycline. Here, we highlight the high risk of exposure to ticks and tick bites within tea estates and its causal relationship to SFG infection, which is increasing in Sri Lanka. Active case detection, notification, surveillance, and community awareness are imperative. Possible preventative measures for tick bites have to be introduced. There is a need to explore the effectiveness of local remedies currently in use.

Background The COVID‐19 pandemic has been accompanied by the largest mobilization of therapeutic convalescent plasma (CCP) in over a century. Initial identification of high titer units was based on dose–response data using the Ortho VITROS IgG assay. The proliferation of severe acute respiratory syndrome coronavirus 2 serological assays and non‐uniform application has led to uncertainty about their interrelationships. The purpose of this study was to establish correlations and analogous cutoffs between multiple serological assays. Methods We compared the Ortho, Abbott, Roche, an anti‐spike (S) ELISA, and a virus neutralization assay. Relationships relative to FDA‐approved cutoffs under the CCP emergency use authorization were identified in convalescent plasma from a cohort of 79 donors from April 2020. Results Relative to the neutralization assay, the spearman r value of the Ortho Clinical, Abbott, Roche, anti‐S ELISA assays was 0.65, 0.59, 0.45, and 0.76, respectively. The best correlative index for establishing high‐titer units was 3.87 signal‐to‐cutoff (S/C) for the Abbott, 13.82 cutoff index for the Roche, 1:1412 for the anti‐S ELISA, 1:219 by the neutralization assay, and 15.9 S/C by the Ortho Clinical assay. The overall agreement using derived cutoffs compared to a neutralizing titer of 1:250 was 78.5% for Abbott, 74.7% for Roche, 83.5% for the anti‐S ELISA, and 78.5% for Ortho Clinical. DISCUSSION Assays based on antibodies against the nucleoprotein were positively associated with neutralizing titers and the Ortho assay, although their ability to distinguish FDA high‐titer specimens was imperfect. The resulting relationships help reconcile results from the large body of serological data generated during the COVID‐19 pandemic.

Context.— The ongoing COVID-19 pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has elicited a surge in demand for serologic testing to identify previously infected individuals. In particular, antibody testing is crucial in identifying COVID-19 convalescent plasma, which has been approved by the Food and Drug Administration under the Emergency Use Authorization for use as passive immunotherapy for hospitalized patients infected with COVID-19. Currently, high-titer COVID-19 convalescent plasma can be qualified by Ortho's Vitros COVID-19 IgG antibody test. Objective.— To explore the use of an efficient testing method to identify high-titer COVID-19 convalescent plasma for use in treating COVID-19–infected patients and track COVID-19 positivity over time. Design.— We evaluated an enzyme-linked immunosorbent assay (ELISA)–based method that detects antibodies specific to the SARS-CoV-2 receptor binding domain (RBD) with individual and pooled plasma samples and compared its performance against the Vitros COVID-19 IgG antibody test. Using the pooled RBD-ELISA (P-RE) method, we also screened more than 10 000 longitudinal healthy blood donor samples to assess seroprevalence. Results.— P-RE demonstrates 100% sensitivity in detecting Food and Drug Administration–defined high-titer samples when compared with the Vitros COVID-19 IgG antibody test. Overall sensitivity of P-RE when compared with the Vitros COVID-19 IgG antibody test and our individual sample RBD-ELISA (I-RE) were 83% and 56%, respectively. When screening 10 218 healthy blood donor samples by P-RE, we found the seroprevalence correlated with the local infection rates with a correlation coefficient of 0.21 (P < .001). Conclusions.— Pooling plasma samples can be used to efficiently screen large populations for individuals with high-titer anti–RBD antibodies, important for COVID-19 convalescent plasma identification.

Early in the SARS-CoV-2 pandemic, convalescent plasma (CP) therapy was proposed as a treatment for severely ill patients. We conducted a CP treatment protocol under the Mayo Clinic Extended Access Program at University Hospital Brooklyn (UHB). Potential donors were screened with a lateral flow assay (LFA) for IgM and IgG antibodies against the SARS-CoV-2 S1 receptor-binding domain (RBD). Volunteers that were LFA positive were tested with an ELISA to measure IgG titers against the RBD. Subjects with titers of at least 1:1024 were selected to donate. Most donors with positive LFA had acceptable titers and were eligible to donate. Out of 171 volunteers, only 65 tested positive in the LFA (38.0%), and 55 (32.2%) had titers of at least 1:1024. Before our donation program started, 31 CP units were procured from the New York Blood Center (NYBC). Among the 31 CP units that were obtained from the NYBC, 25 units (80.6%) were positive in the LFA but only 12 units (38.7%) had titers of at least 1:1024. CP was administered to 28 hospitalized COVID-19 patients. Patients who received low titer CP, high titer CP and patients who did not receive CP were followed for 45 days after presentation. Severe adverse events were not associated with CP transfusion. Death was a less frequent outcome for patients that received high titer CP (>1:1024) 38.6% mortality, than patients that received low titer CP (≤1:1024) 77.8% mortality.

Enzymes and cell factories play essential roles in industrial biotechnology for the production of chemicals and fuels. The properties of natural enzymes and cells often cannot meet the requirements of different industrial processes in terms of cost-effectiveness and high durability. To rapidly improve their properties and performances, laboratory evolution equipped with high-throughput screening methods and facilities is commonly used to tailor the desired properties of enzymes and cell factories, addressing the challenges of achieving high titer and the yield of the target products at high/low temperatures or extreme pH, in unnatural environments or in the presence of unconventional media. Droplet microfluidic screening (DMFS) systems have demonstrated great potential for exploring vast genetic diversity in a high-throughput manner (>106/h) for laboratory evolution and have been increasingly used in recent years, contributing to the identification of extraordinary mutants. This review highlights the recent advances in concepts and methods of DMFS for library screening, including the key factors in droplet generation and manipulation, signal sources for sensitive detection and sorting, and a comprehensive summary of success stories of DMFS implementation for engineering enzymes and cell factories during the past decade.

Objective: We aimed to determine the efficacy of rapid antigen tests, clinical signs, and McIsaac / modified Centor clinical scoring systems in the diagnosis of Group A streptococcus (GAS) at children.Materials and Methods: Subjects aged 3-14 years who presented with acute tonsillopharyngitis were questioned about their sociodemographic properties and symptoms. Their clinical signs and McIsaac / modified Centor scores were recorded. They underwent a rapid streptococcal antigen test and throat culture sampling.Results: GAS proliferated in culture %11 of cases. The risk of culture positivity was 4.8 times greater in children aged 6 years or older. There was a significant correlation between culture positivity and muscle pain, tonsillar edema. Rapid strep test had a sensitivity of 75% and a specifity of 100% for the diagnosis of streptococcal tonsillopharyngitis. Rapid strep test showed a sensitivity of 80% and a specifity of 100% in children with a McIsaac / modified Centor score of 4-5.Conclusions: Unnecessary antibiotic use for tonsillopharyngitis is an important problem. Therefore, it is ideal to order throat culture and act accordingly in every case suggesting GAS infection. However, when culture is not possible, rapid strep testing and McIsaac / modified Centor scoring are effective in guiding diagnosis and treatment., Amaç: Bu çalışmada çocuklarda grup A streptokok (GAS) infeksiyonlarını saptamada hızlı antijen testi, klinik bulgular ile McIsaac / modifiye Centor klinik skorlamalarının etkinliğinin saptanması amaçlandı.Materyal ve Metot: Çalışmada akut tonsillofarenjitle başvuran 3-14 yaş arası olgular sosyodemografik ve semptomlar yönünden sorgulandı. Klinik bulguları ve McIsaac / modifiye Centor skorlamaları kaydedildi. Olguların tümüne hızlı streptokok antijen testi uygulandı ve boğaz kültürü çalışıldı. Bulgular: Olguların % 11 inde GAS kültürde üredi. Altı yaş ve üzeri çocuklarda kültür pozitifliği riski 4.8 kat daha fazla saptandı. Kas ağrısı ve tonsiller ödem ile kültür pozitifliği arasında istatiksel anlamlı ilişki mevcuttu Hızlı antijen testi streptokok tonsillofarenjiti tanısında %75 duyarlılığa, %100 özgüllüğe sahip olarak bulundu. McIsaac / modifiye Centor skoru 4-5 olan çocuklarda hızlı antijen testi streptokok tonsillofarenjiti tanısında %80 duyarlılık, %100 özgüllük gösterdi. Sonuç: Akut tonsillofarenjitte gereksiz antibiyotik kullanımı önemli bir sorundur. Bu nedenle GAS infeksiyonunu düşündüren her olguda boğaz kültürünün istenmesi ve ona göre hareket edilmesi ideal olandır. Ancak kültürün yapılamadığı durumlarda tanı ve tedaviyi yönlendirmede hızlı strep testi ve McIsaac / modifiye Centor skorlaması etkilidir.

Acquired hemophilia due to inhibitor antibodies to factor VIII (FVIII) is a very rare entity in neonatal period. Maternal IgG antibodies may cross the placenta and can cause life-threatening hemorrhages in newborns. Here, we represent a newborn who diagnosed as a transplacental acquired hemophilia A. A very high titer of inhibitor level (320 Nijmegen-Bethesda unit) was detected in plasma due to transplasental transfer in this case. According to the best of our knowledge the baby had the highest inhibitor level in neonatal period in the literature. Bleeding complications including intracranial hemorrhage secondary to this condition were reported before. Therefore, to prevent possible life complications, prophylactic recombinant FVIIa was administered in the presenting case and any bleeding event was not observed during follow-up. In conclusion, using prophylactic recombinant FVIIa in newborns is a safe choice for transplacental acquired hemophilia A.

Background The application of convalescent plasma (CP) is currently seen as a feasible therapeutic approach in the treatment of COVID-19 Aim To analyze the experience of recruiting a donor cohort from COVID-19 convalescents for banking of CP as part of a pilot project at the Moscow Healthcare Department Materials and methods A retrospective research included 493 COVID-19 convalescents as potential CP donors, all examined at the Sklifosovsky Research Institute for Emergency Medicine CP was banked using the plasmapheresis method Only those donors with a documented medical history of COVID-19, which was confi rmed by polymerase chain reaction of SARS-CoV-2 RNA in pharyngeal swabs, and no sooner than 14 days after complete recovery were eligible for donation Viral neutralizing activity (VNA) was chosen as the key characteristic of the immunological viability of CP All the donors having VNA titers were characterized in terms of gender, age, time interval since the disease onset, regression of clinical symptoms and clinical features of the COVID 19 course Results Effective (1:160 or more) and acceptable (1:80) VNA titers were found in 21 1 % and 24 75 % of donors, respectively Signifi cant predictors for a donor having a high VNA titer included: male sex, age over 36 years and verifi ed viral pneumonia The absence of a signifi cant body temperature response (38 5 °С) can be considered as a negative marker of a potential donor Введение Трансфузии плазмы антиковидной патогенредуцированной (ПАП) рассматривается как один из методов лечения COVID-19 Цель: проанализировать опыт формирования донорского резерва из реконвалесцентов COVID-19 для заготовки ПАП Материалы и методы В ретроспективное исследование включено 493 реконвалесцента COVID-19, проходивших обследование в ГБУЗ «НИИ скорой помощи им Н В Склифосовского ДЗМ» в качестве потенциальных доноров ПАП Заготовку ПАП осуществляли методом плазмафереза К процедуре плазмодачи допускали доноров, у которых в анамнезе была перенесенная инфекция COVID-19, подтвержденная выявлением методом полимеразной цепной реакции РНК SARS-CoV-2 в мазках из глотки, наличие медицинской документации, срок с момента разрешения заболевания не менее 14 суток В качестве характеристики иммунологической состоятельности ПАП был выбран титр вируснейтрализующих антител (ВНА) Сопоставлены характеристики доноров (пол, возраст, давность с момента начала заболевания и регресса клинической симптоматики, особенности течения COVID-19) с титром ВНА Результаты Эффективный титр ВНА (1:160 и более) выявлен у 21,10 % доноров, допустимый (1:80) - у 24,75 % Значимыми предикторами высокого титра ВНА оказались: мужской пол донора, возраст старше 36 лет, наличие верифицированной вирусной пневмонии Отсутствие значимой температурной реакции (38,5 °C) может рассматриваться как отрицательный маркер для привлечения потенциального донора Заключение Для получения ПАП с высокими титрами ВНА оптимально привлечение в качестве доноров-реконвалесцентов мужчин, переболевших COVID-19 с клинической картиной вирусной пневмонии и значимой температурной реакцией

Type 1 diabetes mellitus (T1DM) is mainly triggered by autoimmune β-cell destruction, usually leading to absolute insulin deficiency. Regarding the speed of β-cell destruction, there are large variations depending on age. In some adult cases, sufficient β-cell function is sometimes retained for a relatively long period and eventually they become dependent on insulin for survival. It is known that even in subjects with T1DM showing high titers of such antibodies, insulin secretory capacity is preserved under several conditions such as “honeymoon” period and slowly progressive T1DM (SPIDDM). Herein, we reported the acute onset T1DM subject with long-term preservation of β-cell function, although his anti-GAD antibody and anti-IA-2 antibody titers were very high for more than 4 years. This case is very important in that his β-cell function was preserved with dipeptidyl peptidase-4 inhibitor alone. This means that there are large variations in the speed of β-cell destruction in the onset of T1DM.

A 61-year-old man presents with painless progressive weakness and was found to have myopathy both clinically and on diagnostic workup.The etiology of his myopathy is the first reported case of anti-SRP myopathy and sarcoidosis overlap syndrome. The high titer anti-SRP antibody and phenotype support the diagnosis of an overlap syndrome, defined as multiple distinct autoimmune diseases occurring together.This case highlights the wide differential for myopathies and the different testing and components to consider when approaching a diagnosis.

Convalescent plasma (CP) from patients recovered from COVID-19 is one of the most studied anti-viral therapies against SARS-COV-2 infection. The aim of this study is to summarize the evidence from the available systematic reviews on the efficacy and safety of CP in COVID-19 through an overview of the published systematic reviews (SRs). A systematic literature search was conducted up to August 2021 in Embase, PubMed, Web of Science, Cochrane and Medrxiv databases to identify systematic reviews focusing on CP use in COVID-19. Two review authors independently evaluated reviews for inclusion, extracted data and assessed quality of evidence using AMSTAR (A Measurement Tool to Assess Reviews) and GRADE tools. The following outcomes were analyzed: mortality, viral clearance, clinical improvement, length of hospital stay, adverse reactions. In addition, where possible, subgroup analyses were performed according to study design (e.g., RCTs vs. non-RCTs), CP neutralizing antibody titer and timing of administration, and disease severity. The methodological quality of included studies was assessed using the checklist for systematic reviews AMSTAR-2 and the GRADE assessment. Overall, 29 SRs met the inclusion criteria based on 53 unique primary studies (17 RCT and 36 non-RCT). Limitations to the methodological quality of reviews most commonly related to absence of a protocol (11/29) and funding sources of primary studies (27/29). Of the 89 analyses on which GRADE judgements were made, effect estimates were judged to be of high/moderate certainty in four analyses, moderate in 38, low in 38, very low in nine. Despite the variability in the certainty of the evidence, mostly related to the risk of bias and inconsistency, the results of this umbrella review highlight a mortality reduction in CP over standard therapy when administered early and at high titer, without increased adverse reactions.

Treatment options exist for patients with severe hemophilia and high titer factor VIII inhibitors but is often inadequate. Few studies have been conducted to evaluate the utility of short-term corticosteroid therapy for improvement in bleeding complications and temporary or sustained resolution of inhibitors in these patients. We describe 2 patients with acute muscular hematomas successfully treated with 4 to 5 days of oral adjuvant corticosteroid therapy resulting in improvement in their acute bleeds and temporary reduction of inhibitors. Thus, the addition of corticosteroids to traditional therapy of hemophilia with inhibitors may be beneficial in some patients. In those with impending compartment syndrome steroids may improve edema and bleeding symptoms preventing the need for surgical interventions.

Convalescent plasma therapy has been used successfully in the past to treat respiratory infections. In SARS-CoV-2, there was initially strong evidence in favor of convalescent plasma therapy from a large observational study but the evidence from recent randomized controlled trials has been mixed. However, two of those studies provided convalescent plasma therapy on average 8 days after diagnosis despite earlier data proving that the therapy is most effective when given within 3 days of diagnosis. Another more recent randomized controlled trial found evidence in support of convalescent plasma therapy and we believe that it is no coincidence that they administered convalescent plasma therapy within 3 days of symptom onset. We call for more robustly planned randomized controlled studies to further reliably determine the efficacy of convalescent plasma therapy against SARS-CoV-2. Progress has been made with developing a vaccine but there is likely to be a substantial lag in widespread administration of the vaccine, especially in poorer countries. We therefore propose that patients with SARS-CoV-2 infection should be considered for early ambulatory administration of high-dose convalescent plasma in order to reduce the burden of severe SARS-CoV-2 disease.

A convalescent, non-severe, patient with COVID-19 was enrolled as a hyper-immune plasma voluntary donor by the Immuno-Hematology and Transfusion Unit of the Regina Elena National Cancer Institute in Rome, under the TSUNAMI national study criteria. During a nearly 6-month period (May–October 2020), the patient was closely monitored and underwent four hyperimmune plasma collections. Serum SARS-CoV-2 (anti-S + anti-N) IgG and IgM, anti-S1 IgA, and neutralizing titers (NTs) were measured. Anti-SARS-CoV-2 antibody levels steadily decreased. No correlation was found between anti-S/anti-N IgG and IgM levels and viral NT, measured by either a microneutralization test or the surrogate RBD/ACE2-binding inhibition test. Conversely, NTs directly correlated with anti-S1 IgA levels. Hyperimmune donor plasma, administered to five SARS-CoV-2 patients with persistent, severe COVID-19 symptoms, induced short-term clinical and pathological improvement. Reported data suggest that high NTs can persist longer than expected, thus widening hyperimmune plasma source, availability, and potential use. In vitro RBD/ACE2-binding inhibition test is confirmed as a convenient surrogate index for neutralizing activity and patients’ follow-up, suitable for clinical settings where biosafety level 3 facilities are not available. IgA levels may correlate with serum neutralizing activity and represent a further independent index for patient evaluation.

Contamination of fomites by human norovirus (HuNoV) can initiate and prolong outbreaks. Fomite swabbing is necessary to predict HuNoV exposure and target interventions. Historically, swab recovered HuNoV has been measured by molecular methods that detect viral RNA but not infectious HuNoV. The recent development of HuNoV cultivation in human intestinal enteroids (HIEs) enables detection of infectious HuNoV. It is unknown if the swabbing process and swab matrix will allow for cultivation of fomite recovered HuNoV. We used HIEs to culture swab-recovered HuNoV GII.4 Sydney from experimentally infected surfaces—a hospital bed tray (N = 32), door handle (N = 10), and sanitizer dispenser (N = 11). Each surface was swabbed with macrofoam swabs premoistened in PBS plus 0.02% Tween80. Swab eluate was tested for infectious HuNoV by cultivation in HIE monolayers. Infectious HuNoV can be recovered from surfaces inoculated with at least 105 HuNoV genome equivalents/3 cm2. In total, 57% (N = 53) of recovered swabs contained infectious HuNoV detected by HIEs. No difference in percent positive swabs was observed between the three surfaces at p = 0.2. We demonstrate that fomite swabbing can be combined with the HIE method to cultivate high titer infectious HuNoV from the environment, filling a significant gap in HuNoV detection. Currently, high titers of HuNoV are required to measure growth in HIEs and the HIE system precludes absolute quantification of infectious viruses. However, the HIE system can provide a binary indication of infectious HuNoV which enhances existing detection methods. Identification of infectious HuNoVs from swabs can increase monitoring accuracy, enhance risk estimates, and help prevent outbreaks.

Invasive cervical cancer (ICC) with very low titer of high-risk human papillomavirus (HPV) has worse clinical outcome than cases with high titer, indicating a difference in molecular etiology. Fresh-frozen ICC tumors (n = 49) were classified into high- and low-HPV-titer cases using real-time PCR-based HPV genotyping. The mutation spectra were studied using the AmpliSeq Comprehensive Cancer Panel and the expression profiles using total RNA sequencing, and the results were validated using the AmpliSeq Transcriptome assay. HPV DNA genotyping and RNA sequencing showed that 16.6% of ICC tumors contained very low levels of HPV DNA and HPV transcripts. Tumors with low HPV levels had more mutations with a high allele frequency and fewer mutations with low allele frequency relative to tumors with high HPV titer. A number of genes showed significant expression differences between HPV titer groups, including genes with somatic mutations. Gene ontology and pathway analyses implicated the enrichment of genes involved in DNA replication, cell cycle control and extracellular matrix in tumors with low HPV titer. The results indicate that in low titer tumors, HPVs act as trigger of cancer development whereas somatic mutations are clonally selected and become drivers of the tumor development process. In contrast, in tumors with high HPV titer the expression of HPV oncoproteins plays a major role in tumor development and the many low frequency somatic mutations represent passengers. This putative subdivision of invasive cervical tumors may explain the higher radiosensitivity of ICC tumors with high HPV titer and thereby have consequences for clinical management.

IMPORTANCE: Convalescent plasma is a proposed treatment for COVID-19. OBJECTIVE: To assess clinical outcomes with convalescent plasma treatment vs placebo or standard of care in peer-reviewed and preprint publications or press releases of randomized clinical trials (RCTs). DATA SOURCES: PubMed, the Cochrane COVID-19 trial registry, and the Living Overview of Evidence platform were searched until January 29, 2021. STUDY SELECTION: The RCTs selected compared any type of convalescent plasma vs placebo or standard of care for patients with confirmed or suspected COVID-19 in any treatment setting. DATA EXTRACTION AND SYNTHESIS: Two reviewers independently extracted data on relevant clinical outcomes, trial characteristics, and patient characteristics and used the Cochrane Risk of Bias Assessment Tool. The primary analysis included peer-reviewed publications of RCTs only, whereas the secondary analysis included all publicly available RCT data (peer-reviewed publications, preprints, and press releases). Inverse variance–weighted meta-analyses were conducted to summarize the treatment effects. The certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation. MAIN OUTCOMES AND MEASURES: All-cause mortality, length of hospital stay, clinical improvement, clinical deterioration, mechanical ventilation use, and serious adverse events. RESULTS: A total of 1060 patients from 4 peer-reviewed RCTs and 10 722 patients from 6 other publicly available RCTs were included. The summary risk ratio (RR) for all-cause mortality with convalescent plasma in the 4 peer-reviewed RCTs was 0.93 (95% CI, 0.63 to 1.38), the absolute risk difference was −1.21% (95% CI, −5.29% to 2.88%), and there was low certainty of the evidence due to imprecision. Across all 10 RCTs, the summary RR was 1.02 (95% CI, 0.92 to 1.12) and there was moderate certainty of the evidence due to inclusion of unpublished data. Among the peer-reviewed RCTs, the summary hazard ratio was 1.17 (95% CI, 0.07 to 20.34) for length of hospital stay, the summary RR was 0.76 (95% CI, 0.20 to 2.87) for mechanical ventilation use (the absolute risk difference for mechanical ventilation use was −2.56% [95% CI, −13.16% to 8.05%]), and there was low certainty of the evidence due to imprecision for both outcomes. Limited data on clinical improvement, clinical deterioration, and serious adverse events showed no significant differences. CONCLUSIONS AND RELEVANCE: Treatment with convalescent plasma compared with placebo or standard of care was not significantly associated with a decrease in all-cause mortality or with any benefit for other clinical outcomes. The certainty of the evidence was low to moderate for all-cause mortality and low for other outcomes.

Hemorrhage in the central nervous system is the most severe and debilitating manifestation affecting patients with hemophilia A. The spinal epidural space is the most unusual and clinically challenging site of central nervous system hemorrhage in hemophilia A. These patients often show insidious neurological signs and symptoms that delay diagnosis and treatment. We share our experience treating a 4-year-old male patient with severe hemophilia A and high titer inhibitors with a spontaneous spinal epidural hematoma. The patient presented initially with intense headache and neck pain. After blood tests and imaging studies, bypassing agent therapy with recombinant-activated factor VII was used until discharge; this was later replaced with emicizumab. After 18 months, the patient is without neurological sequelae and has not experienced subsequent bleeding episodes. We review the available literature and discuss the relevance of emicizumab compared with standard therapies in the context of spontaneous spinal epidural hematoma.

The occurrence of a spinal epidural hematoma in patients with hemophilia A with high-titer VIII inhibitors is extremely rare and intractable. A 15-year-old male patient presented to our institution with acute back pain and progressive sensorimotor disorder of the bilateral lower extremities. He had hemophilia A with high-titer VIII inhibitors and had experienced recurrent hemorrhagic episodes for many years. Prompt magnetic resonance imaging revealed a spinal epidural hematoma. We administered bypassing agent therapy with prothrombin complex concentrates and performed intensive neurological monitoring. The neurological dysfunction improved with days, and the patient recovered completely within 3 weeks. Magnetic resonance imaging 1 year later showed that the hematoma had been completely absorbed. Spinal epidural hematomas in patients with hemophilia A with high-titer inhibitors can be successfully treated using prothrombin complex concentrates. Multidisciplinary discussions based on intensive neurological monitoring should be performed as early in the clinical course as possible.

Background The presence or absence of human leukocyte antigen (HLA) antibodies, especially the strength of donor‐specific HLA antibodies (DSAs), has important roles in clinical evaluation and diagnostic decision‐making for solid‐organ transplantation. Dilution patterns help to give a new sight of HLA epitopes. “Epitope matching” is likely to lower the risk of developing DSA and increase the likelihood of matching a compatible donor. Methods We collected data evaluating HLA antibodies with a titration study using mean fluorescence intensity. Results Diluting the serum of recipients can reduce potential inhibitory effects, accurately evaluate the intensity of donor‐specific HLA antibodies, and guide surgeons to take or not take intervention measures. Dilution patterns also help to give a new sight of HLA epitopes. Conclusion We believe that from the viewpoint of HLA antibodies, the dilution model can provide new tools and insights for the study of HLA epitopes.

The new coronavirus SARS-CoV-2 has become a global pandemic, which has had a huge impact on the lives of people around the world and has caused huge impacts and losses on global economic development To now, there is still no effective drug or therapy against coronavirus A large number of studies have shown that vaccines are the ultimate weapon to eliminate major infectious diseases The development of new vaccines against new coronaviruses is the best way to prevent new coronavirus infections In this study, we developed a new vaccine against the new coronavirus by combining our self-developed nano adjuvant loaded with carnosine graphene oxide adjuvant with loaded with CpG molecule and RBD protein antigen Our results showed that this vaccine can produce high titer anti-SARS-CoV-2 RBD antibody neutralizing SARS-CoV-2 in mice within 2 weeks

Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 remains a global threat with few proven efficacious treatments. Transfusion of convalescent plasma collected from donors who have recovered from COVID-19 disease has emerged as a promising therapy and has been granted emergency use authorization by the U.S. Food and Drug Administration (FDA). We recently reported results from interim analysis of a propensity-score matched study suggesting that early treatment of COVID-19 patients with convalescent plasma containing high titer anti-spike protein receptor binding domain (RBD) IgG significantly decreases mortality. We here present results from 60-day follow up of our cohort of 351 transfused hospitalized patients. Prospective determination of ELISA anti-RBD IgG titer facilitated selection and transfusion of the highest titer units available. Retrospective analysis by the Ortho VITROS IgG assay revealed a median signal/cutoff (S/C) ratio of 24.0 for transfused units, a value far exceeding the recently FDA-required cutoff of 12.0 for designation of high titer convalescent plasma. With respect to altering mortality, our analysis identified an optimal window of 44 hours post-hospitalization for transfusing COVID-19 patients with high titer convalescent plasma. In the aggregate, the analysis confirms and extends our previous preliminary finding that transfusion of COVID-19 patients soon after hospitalization with high titer anti-spike protein RBD IgG present in convalescent plasma significantly reduces mortality.

Introduction Adult pharyngitis is rarely attributable to group A streptococci. Utilization of a rapid streptococcal antigen test (RADT) may improve appropriate prescribing for bacterial pharyngitis. Methods Clinic 1 performed RADTs with subsequent Group A DNA probe test (GADNA) from November 2014-March 2015 and November 2015-March 2016 while Clinic 2 was the control clinic, then implemented the RADT with a GADNA from November 2015-March 2016. All GADNA results were obtained for each clinic from October 2013-March 2016. Results At Clinic 1, 22.2% versus 8.5% of patients received inappropriately prescribed antibiotics for a GADNA or RADT result, respectively (p=0.048). For Clinic 2, 51.1% compared to 21.4% of patients were inappropriately prescribed antibiotic for a GADNA or RADT result, respectively (p=0.038). Overall, the total GADNA without RADT testing or RADTs with subsequent GADNA testing, 41.6% versus 11% of patients were inappropriately prescribed antibiotics, respectively (p= Conclusion Utilizing the RADT prevented unnecessary prescribing of antibiotics in adults.

We present a case of a two-year-old boy with hemophilia A and high titer factor inhibitor, who developed forearm compartment syndrome two days after taking blood samples for a regular check-up of serum concentration of Factor VIII. Emergency fasciotomy was performed to prevent Volkmann contracture. The patient needed bypass therapies including recombitant activated factor VII (rFVIIa), activated prothrombin complexes (aPCC), factors VII・X (MC7-10), and transfusions. Eleven days after the surgical intervention, he was discharged without any functional loss in the affected upper extremity. Early surgical intervention prevented compartment syndrome of affected upper extreme.

Acquired coagulation factor inhibitor is a rare coagulation disorder. We herein report a patient with acquired factor V inhibitor showing a decrease in multiple coagulation factor activities. A high titer of factor V inhibitor presumably led to a marked inhibition of factor V activity in the specific factor-deficient plasma used in coagulation factor activity assays based on either an activated partial thromboplastin time (APTT) or prothrombin time (PT) clotting assay, resulting in false low values of the coagulation activity. We re-examined the coagulation factor activity using several dilutions of the patient's plasma and confirmed that the high factor V inhibitor titer had caused an apparent decrease in multiple coagulation factor activities.

Background Hemophilia A (HA) is an inherited X-linked bleeding disease with costly treatment, especially for high titer inhibitory patients. Emicizumab, a new humanized bispecific antibody, has been approved for use to prevent or reduce the frequency of bleeding episodes in HA patients with inhibitors. This study evaluated the cost-utility of emicizumab prophylaxis (EP) in comparison with recombinant factor VII activated on-demand treatment in HA patients with inhibitors. Methods A life-time Markov model with payer and societal perspectives was developed in different age groups with different annual bleeding rates (ABR). Efficacy of treatments were extracted from HAVEN trials. Utilities were retrieved from published evidence. Costs were calculated based on Iran food and drug administration official website, national tariff book for medical services and hospital data. One-way deterministic sensitivity analysis was performed. Results EP was dominant choice in comparison with on-demand administration of recombinant factor VII activated in all age groups with ABR 20 and 25, and it remained dominant in patients with age 2 and age 12 at start point with ABR 16 and 17. The reported incremental cost-effectiveness ratio for the group with ABR 18 at the age 20, was 12,936 United States Dollars which is lower than the acceptable threshold of cost-effectiveness in Iran (1-3 gross domestic product per capita) and EP can be considered as cost-effective choice in this scenario. Conclusion EP was found to be a dominant and cost-effective choice for Iranian HA patients with factor VIII inhibitors with ABR 18 and above with considerable cost saving.

HPV infections are associated with human cancers. Although three prophylactic vaccines have been approved to protect against HPV infections, the vaccines require cold-chain storage and may not be suitable for third world countries with less developed refrigeration facilities. We previously developed a bacteriophage L2 virus-like particle (VLP)-based candidate vaccine, which elicited broadly protective antibodies against diverse HPV types. Spray-drying of MS2-16L2 VLPs into a dry powder enhanced the stability of these VLPs. Building on these studies, we assessed the long-term stability and immunogenicity of the spray-dried VLPs. Mice immunized with a single dose of spray-dried MS2-16L2 VLPs, which had been stored for 14 months at room temperature (RT), were partially protected from challenge with a high dose of HPV16, one year after immunization. However, immunization with two doses of MS2-16L2 VLPs stored at RT for 34 months elicited high titer anti-HPV antibodies. More importantly, this group of mice showed significant protection from HPV16, 4 months after immunization. These results suggest that spray-dried MS2-16L2 VLPs retain their effectiveness after long-term storage at RT, and may be suitable in third world countries with less developed refrigeration facilities. Keywords: HPV vaccine, Bacteriophage L2-VLPs, Longevity, Formulation, Spray-drying, Thermostability

Objectives Group A β hemolytic streptococcus (GABHS) is the main bacterial case of tonsillopharyngitis in children, but most cases of tonsillopharyngitis are viral. Rapid diagnosis and early antibiotherapy of GABHS infections are important to help prevent suppurative and nonsuppurative complications. This retrospective study investigated the using of the rapid streptococcal antigen detection test and traditional throat culture in diagnosing tonsillopharyngitis in children. Materials and Methods Retrospectively, the laboratory results of throat culture and rapid strep A test (optic immunoassay) of 1,654 children were compared. Results Of the 1,654 subjects, the rapid test was performed in 1,110 (67.1%), and throat culture was performed in 930 (56.2%). Both tests were performed in 479 (31.1%) patients and the correlation between the tests was 87.2%. The power of the correlation between the two tests was 0.6 ( p Conclusion The rapid strep A testing is more practical and quick to detect GABHS. This can be an important strategy to reduce unnecessary antibiotic use. Throat culture should be used to confirm the negative findings of the rapid test.

espanolResumen Introduccion Los estreptococos β-hemoliticos del grupo C y G como Streptococcus dysgalactiae subsp. equisimilis y Streptococcus anginosus son microorganismos oportunistas, responsables de un amplio rango de infecciones en animales. Las infecciones producidas por estas especies en seres humanos poseen un espectro clinico similar al del resto de estreptococos β -hemoliticos y afectan especialmente a pacientes en las edades extremas de la vida, inmunosuprimidos con neoplasias, diabetes, alcoholismo o usuarios de drogas por via parenteral. Diagnostico La deteccion rapida de antigeno estreptococico no descarta la infeccion por los grupos C y G, ya que esta tecnica solo detecta antigenos de S. pyogenes (grupo A). Es necesaria la realizacion de un cultivo bacteriologico de la muestra de interes segun el cuadro clinico del paciente como el exudado faringoamigdalar, hisopado o biopsia de lesion de piel, aspirado de absceso, sangre, liquido articular, etc. Tratamiento La penicilina continua siendo la primera eleccion para la infeccion por los grupos C y G, teniendo en cuenta la ausencia de resistencias comunicadas en la literatura y su bajo coste. Las cefalosporinas de tercera generacion y clindamicina son utiles para el tratamiento de las infecciones invasoras. Las elevadas tasas de resistencias a macrolidos en nuestro medio desaconsejan su uso. EnglishIntroduction Group C and G β-hemolytic streptococci such as Streptococcus dysgalactiae subsp. equisimilis, and Streptococcus anginosus are opportunistic microorganisms that produce a wide range of infections in animals. Infections produced by these species in humans have a clinical spectrum similar to those produce by Group A streptococci and affect especially patients in the extreme ages of life, immunosuppressed with neoplasias, diabetes, alcoholism or injecting drug users. Diagnosis Rapid detection of streptococcal antigen does not rule out infection by groups C and G as this technique only detects Group A antigens. It is necessary to carry out a bacteriological culture of the sample of interest according to the clinical presentation, such as pharyngeal swab, swab or skin lesion biopsy, abscess aspirate, blood, joint fluid, etc. Treatment Penicillin remains the first choice for the treatment of infections produced by Groups C and G, taking into account the absence of resistance reported in the literature and its low cost. Third-generation cephalosporins and clindamycin are useful for the treatment of invasive infections. The high rates of resistance to macrolides in our environment discourage its use.

Background In Colombia, hemophilia is considered a high-cost disease, and hemophilia A with high-titer inhibitors may be responsible for a significant economic pressure on the Colombian health system. Objectives To estimate the direct cost of care for patients with hemophilia A with high-titer inhibitors in Colombia, from the perspective of the health system. Methods A cost-of-illness study was carried out using standard case methodology, which was designed based on literature review and validation by expert consensus. Scenarios were established for adults and children, including cases of prophylaxis, immune tolerance induction, bleeding, and surgery. The frequencies were taken from the official report for Colombia, issued by the High-Cost Account 2017 (reported 2018). The prices were obtained from the list of regulated medicines in the country. The cost estimate is presented with a range of values by weight (between 10 kg and 90 kg). Results The total estimated cost per year for Colombia was US $44 905 252 (between US $32 260 497 and US $58 202 393). The average cost per year calculated for a patient was US $498 947 (between US $358 450 and US $646 693). A total of 99.8% of the estimated cost was directly related to the cost of the coagulation factors and bypassing agents. Conclusions Hemophilia A with high-titer inhibitors is a disease that generates significant pressure on the Colombian health system, mainly linked to the cost of factors and bypassing agents.

To inform our ongoing efforts to develop defining features to be incorporated into a novel set of classification criteria for discoid lupus erythematosus (DLE), we conducted a literature review using the Ovid MEDLINE database. A search was performed to identify studies reporting criteria used to distinguish DLE from other cutaneous lupus erythematosus subtypes. We examined which clinical, histopathologic, and serologic features have data to support their use as effective features in distinguishing DLE from other potential disease mimickers and cutaneous lupus subsets. Through our search, we were also able to identify gaps that exist in the literature which can inform future directions for research endeavors. We found that localization of lesions, characteristic features of damage, and the absence of high titer Ro/SSA antibody seem most effective in differentiating DLE from other cutaneous lupus erythematosus subtypes. Histopathologic features and class of immunoreactant deposition appear to be less helpful. Keywords: classification, criteria, cutaneous lupus erythematosus, definition, diagnosis, discoid lupus erythematosus

We describe a 43-year-old female whose manifestations fulfilled the diagnostic criteria of aquaporin-4 IgG negative neuromyelitis optica spectrum disorders (NMOSD). High titer of glial fibrillary acidic protein (GFAP) antibody was detected in cerebrospinal fluid. In this case, some symptoms pertained to NMOSD and some to GFAP antibody-related disorders. The patient had a good response to corticosteroids.

Hemophilia is a hereditary disease with impaired blood coagulation due to a genetic deficiency of blood coagulation factors. The development of inhibitors further complicates the course of the disease and management. The case is here reported of a haemophilia patient who presented with coexisting development of high titer inhibitor with Gastrointestinal Stromal Tumor (GIST) diagnosis and was admitted with upper gastrointestinal system bleeding. The patient had no prior history of inhibitor presence. During all procedures including surgery, excellent hemostasis was achieved with rFVIIa treatment and no hemorrhagic complication was observed. To the best of our knowledge, this constitutes the first reported case of GIST associated with inhibitor development in a hemophilia A patient.

BACKGROUND Plasma volume reduction (PVR) may reduce the risk of hemolysis associated with transfusion of plateletpheresis blood products (PLTs) containing ABO-incompatible plasma. But PVR may delay PLT issue. In collaboration with our blood donor center we evaluated an automated screen of PLT for high-titer ABO antibody and to apply PVR to high-titer PLTs. STUDY DESIGN AND METHODS At the donor center, plasma from PLT donors was tested using an automated microplate system (PK7300, Beckman). PK settings were set for a detection cutoff equivalent to 1 in 256 using a manual tube method. The donors associated with high-titer PLTs were characterized by sex and age. In the transfusion service, the number of PVR procedures was evaluated before and after implementation of the high-titer screen. RESULTS During validation, 157 of 1008 PLT units (15%) were positive by the automated method versus 121 (12%) by manual method. After implementation, 2112 of 15,240 PLT units were high-titer, with higher frequency in donations from females versus males (18% vs. 12%, p

Generating purified protein for GLP toxicology studies (GLP-Tox) represents an important and often rate limiting step in the biopharmaceutical drug development process. Toxicity testing requires large amounts of therapeutic protein (>100 g), typically produced in a single 500-2,500 L bioreactor, using the final CHO clonally derived cell line (CDCL). One approach currently used to save time is to manufacture GLP-Tox material using pools of high-producing CHO CDCLs instead of waiting for the final CDCL. Recently, we reported CHO pools producing mAb titers >7 g/L using piggyBac-mediated gene integration (PB CHO pools). In this study, we wanted to leverage high titer PB CHO pools to produce GLP-Tox material. A detailed product quality attribute (PQA) assessment was conducted comparing PB CHO pools to pooled Top4 CDCLs. Four mAbs were evaluated. First, we found that PB CHO pools expressed all four mAbs at high titers (2.8-4.4 g/L in shake flasks). Second, all four PB CHO pools were aged to 55 generations (Gen). All four PB CHO Pools were found to be suitable over 55 Gen. Finally, we performed bioreactor scale-up. PB CHO pool titers (3.7-4.8 g/L) were similar or higher than the pooled Top 4 CDCLs in 5 L bioreactors (2.4-4.1 g/L). The PQAs of protein derived from PB CHO pools were very similar to pooled Top 4 CHO CDCLs according to multiple orthogonal techniques including peptide mapping analysis. Taken together, these results demonstrate the technical feasibility of using PB CHO pools to manufacture protein for GLP-Tox. © 2017 American Institute of Chemical Engineers Biotechnol. Prog., 33:1436-1448, 2017.

Background and aims Positive ANA is one of Criteria for Classification of SLE for ACR and SLICC. As a follow-up to the International Consensus on ANA Patterns (ICAP) initiative (ANApatterns.org), the relevance of each ANA pattern is being re-evaluated. Methods ANA test at 1/80 screening dilution was performed in 269 sequentially selected patients with SLE diagnosis, 918 healthy individuals, and 558 patients with non-SARD conditions. ANA interpretation was the consensus of 3 independent readers using 2 HEp-2 cell slide brands at 400x mag. Conversely, sequentially selected individuals presenting >1/640 titer Nuclear Dense Fine Speckled (DFS) ANA pattern (AC-2) in a large clinical laboratory within a 2 year period had the diagnosis assessed by interview with the respective physician. Results Among 269 consecutive SLE patients, 96.3% had a positive ANA with the following principal nuclear patterns: homogeneous (29.3%), coarse speckled (14.7%), fine speckled (40.1%). Only one patient (0.3%) had the DFS pattern and the reactivity to DFS70 confirmed by ELISA. Conversely, among 118 ANA+ healthy individuals and 102 ANA+ patients with miscellaneous non-SARD conditions, 33% and 17% presented the DFS pattern, respectively. In addition, the 327 consecutive high-titer DFS individuals presented mostly non-SARD conditions or non-specific clinical presentation. Only 7 had possibly SARD-related presentations: 1 anti-phospholipid syndrome, 1 “possible” SLE (polyarthritis, arthritis, chronic urticaria), 1 WG, 1 DLE, 1 PBC, and 1 RA. Conclusions Well-defined anti-DFS ANA, confirmed by antigen-specific reflex testing, should not be considered a criterion for SLE - either in the ACR or SLICC classification criteria.

Background Neutralizing antibodies (NAb) against interferon-beta (IFNβ) affect its treatment efficacy. So far, there are no anti-NAb strategies available. Objectives To investigate if the repeated administration of high-dose IFNβ-1b intravenous in NAb positive multiple sclerosis (MS) patients induces tolerance and establishes IFNβ bioavailability as measured by the induction of myxovirus protein A (MxA). Methods Nine MS patients with NAb titers >500 10-fold reduction units (TRU) received 1500 μg IFNβ-1b intravenously once weekly over three months. Blood samples were collected at screening, monthly during the treatment period (before and four hours after IFNβ administration), and at follow-up after 6 months for determination of NAbs and MxA expression. Results Median NAb titer at baseline was 1429 TRU. NAb titers determined before each infusion did not significantly change over the treatment period and were not different at follow-up compared to baseline. However, NAb titers were significantly decreased four hours after IFNβ infusions (by roughly 50%) and MxA mRNA levels were significantly elevated reaching a median value of 206. Conclusions Weekly intravenous administration of IFNβ in patients with high NAb titers established its bioavailability, but failed to induce tolerance towards IFNβ.