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Shoham Y, Rosenberg L, Hickerson W, Goverman J, Iyer N, Barrera-Oro J, Lipovy B, Monstrey S, Blome-Eberwein S, Wibbenmeyer LA, Scharpenberg M, Singer AJ. Early Enzymatic Burn Debridement: Results of the DETECT Multicenter Randomized Controlled Trial. J Burn Care Res 2024; 45:297-307. [PMID: 37715999 DOI: 10.1093/jbcr/irad142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Indexed: 09/18/2023]
Abstract
Since 1970 surgeons have managed deep burns by surgical debridement and autografting. We tested the hypothesis that enzymatic debridement with NexoBrid would remove the eschar reducing surgery and achieve comparable long-term outcomes as standard of care (SOC). In this Phase 3 trial, we randomly assigned adults with deep burns (covering 3-30% of total body surface area [TBSA]) to NexoBrid, surgical or nonsurgical SOC, or placebo Gel Vehicle (GV) in a 3:3:1 ratio. The primary endpoint was complete eschar removal (ER) at the end of the debridement phase. Secondary outcomes were need for surgery, time to complete ER, and blood loss. Safety endpoints included wound closure and 12 and 24-months cosmesis on the Modified Vancouver Scar Scale. Patients were randomized to NexoBrid (n = 75), SOC (n = 75), and GV (n = 25). Complete ER was higher in the NexoBrid versus the GV group (93% vs 4%; P < .001). Surgical excision was lower in the NexoBrid vs the SOC group (4% vs 72%; P < .001). Median time to ER was 1.0 and 3.8 days for the NexoBrid and SOC respectively (P < .001). ER blood loss was lower in the NexoBrid than the SOC group (14 ± 512 mL vs 814 ± 1020 mL, respectively; P < .0001). MVSS scores at 12 and 24 months were noninferior in the NexoBrid versus SOC groups (3.7 ± 2.1 vs 5.0 ± 3.1 for the 12 months and 3.04 ± 2.2 vs 3.30 ± 2.76 for the 24 months). NexoBrid resulted in early complete ER in >90% of burn patients, reduced surgery and blood loss. NexoBrid was safe and well tolerated without deleterious effects on wound closure and scarring.
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Affiliation(s)
- Yaron Shoham
- Department of Plastic Surgery and Burn Unit, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheba 8400711, Israel
| | - Lior Rosenberg
- Department of Plastic Surgery and Burn Unit, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheba 8400711, Israel
| | - William Hickerson
- Department of Plastic Surgery, College of Medicine, University of Tennessee Health Science Center, Memphis, TN 38163, USA
- Department of Medicine, Firefighters Regional Burn Center, Regional One Health, Memphis, TN 38163, USA
| | - Jeremy Goverman
- Department of Surgery, Sumner Redstone Burn Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Narayan Iyer
- Burn and Blast Medical Countermeasures Program, Division of Chemical, Biological, Radiological/Nuclear Countermeasures (CBRN), Biomedical Advanced Research and Development Authority (BARDA), Administration for Preparedness and Response (ASPR) 20201, HHS
| | - Julio Barrera-Oro
- Burn and Blast Medical Countermeasures Program, Division of Chemical, Biological, Radiological/Nuclear Countermeasures (CBRN), Biomedical Advanced Research and Development Authority (BARDA), Administration for Preparedness and Response (ASPR) 20201, HHS
| | - Bretislav Lipovy
- Department of Burns and Plastic Surgery, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno 60300, Czech Republic
| | - Stan Monstrey
- Department of Plastic and Reconstructive Surgery and Burn Center, University Hospital of Ghent, Ghent 9000, Belgium
| | | | - Lucy A Wibbenmeyer
- Department of Surgery, Carver College of Medicine, University of Iowa Health Care, Iowa City, IA 52242, USA
| | - Martin Scharpenberg
- Universität Bremen, Kompetenzzentrum für Klinische Studien Bremen, Bremen 28359, Germany
| | - Adam J Singer
- Department of Emergency Medicine, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY 11794, USA
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Ambrose N, Amin A, Anderson B, Barrera-Oro J, Bertagnolli M, Campion F, Chow D, Danan R, D'Arinzo L, Drews A, Erlandson K, Fitzgerald K, Garcia M, Gaspar FW, Gong C, Hanna G, Jones S, Lopansri B, Musser J, O'Horo J, Piantadosi S, Pritt B, Razonable RR, Roberts S, Sandmeyer S, Stein D, Vahidy F, Webb B, Yttri J. Neutralizing Monoclonal Antibody Use and COVID-19 Infection Outcomes. JAMA Netw Open 2023; 6:e239694. [PMID: 37093599 PMCID: PMC10126875 DOI: 10.1001/jamanetworkopen.2023.9694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/25/2023] Open
Abstract
Importance Evidence on the effectiveness and safety of COVID-19 therapies across a diverse population with varied risk factors is needed to inform clinical practice. Objective To assess the safety of neutralizing monoclonal antibodies (nMAbs) for the treatment of COVID-19 and their association with adverse outcomes. Design, Setting, and Participants This retrospective cohort study included 167 183 patients from a consortium of 4 health care systems based in California, Minnesota, Texas, and Utah. The study included nonhospitalized patients 12 years and older with a positive COVID-19 laboratory test collected between November 9, 2020, and January 31, 2022, who met at least 1 emergency use authorization criterion for risk of a poor outcome. Exposure Four nMAb products (bamlanivimab, bamlanivimab-etesevimab, casirivimab-imdevimab, and sotrovimab) administered in the outpatient setting. Main Outcomes and Measures Clinical and SARS-CoV-2 genomic sequence data and propensity-adjusted marginal structural models were used to assess the association between treatment with nMAbs and 4 outcomes: all-cause emergency department (ED) visits, hospitalization, death, and a composite of hospitalization or death within 14 days and 30 days of the index date (defined as the date of the first positive COVID-19 test or the date of referral). Patient index dates were categorized into 4 variant epochs: pre-Delta (November 9, 2020, to June 30, 2021), Delta (July 1 to November 30, 2021), Delta and Omicron BA.1 (December 1 to 31, 2021), and Omicron BA.1 (January 1 to 31, 2022). Results Among 167 183 patients, the mean (SD) age was 47.0 (18.5) years; 95 669 patients (57.2%) were female at birth, 139 379 (83.4%) were White, and 138 900 (83.1%) were non-Hispanic. A total of 25 241 patients received treatment with nMAbs. Treatment with nMAbs was associated with lower odds of ED visits within 14 days (odds ratio [OR], 0.76; 95% CI, 0.68-0.85), hospitalization within 14 days (OR, 0.52; 95% CI, 0.45-0.59), and death within 30 days (OR, 0.14; 95% CI, 0.10-0.20). The association between nMAbs and reduced risk of hospitalization was stronger in unvaccinated patients (14-day hospitalization: OR, 0.51; 95% CI, 0.44-0.59), and the associations with hospitalization and death were stronger in immunocompromised patients (hospitalization within 14 days: OR, 0.31 [95% CI, 0.24-0.41]; death within 30 days: OR, 0.13 [95% CI, 0.06-0.27]). The strength of associations of nMAbs increased incrementally among patients with a greater probability of poor outcomes; for example, the ORs for hospitalization within 14 days were 0.58 (95% CI, 0.48-0.72) among those in the third (moderate) risk stratum and 0.41 (95% CI, 0.32-0.53) among those in the fifth (highest) risk stratum. The association of nMAb treatment with reduced risk of hospitalizations within 14 days was strongest during the Delta variant epoch (OR, 0.37; 95% CI, 0.31-0.43) but not during the Omicron BA.1 epoch (OR, 1.29; 95% CI, 0.68-2.47). These findings were corroborated in the subset of patients with viral genomic data. Treatment with nMAbs was associated with a significant mortality benefit in all variant epochs (pre-Delta: OR, 0.16 [95% CI, 0.08-0.33]; Delta: OR, 0.14 [95% CI, 0.09-0.22]; Delta and Omicron BA.1: OR, 0.10 [95% CI, 0.03-0.35]; and Omicron BA.1: OR, 0.13 [95% CI, 0.02-0.93]). Potential adverse drug events were identified in 38 treated patients (0.2%). Conclusions and Relevance In this study, nMAb treatment for COVID-19 was safe and associated with reductions in ED visits, hospitalization, and death, although it was not associated with reduced risk of hospitalization during the Omicron BA.1 epoch. These findings suggest that targeted risk stratification strategies may help optimize future nMAb treatment decisions.
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Affiliation(s)
| | - Alpesh Amin
- Department of Medicine, University of California, Irvine
- Hospital Medicine Program, University of California, Irvine
| | | | - Julio Barrera-Oro
- Biomedical Advanced Research and Development Authority (BARDA), Administration for Strategic Preparedness and Response, US Department of Health and Human Services, Washington, District of Columbia
| | - Monica Bertagnolli
- Division of Surgical Oncology, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Francis Campion
- The MITRE Corporation, Bedford, Massachusetts
- Department of Population Medicine, Harvard Medical School, Boston, Massachusetts
| | - Daniel Chow
- Department of Radiological Sciences, University of California, Irvine
| | - Risa Danan
- The MITRE Corporation, Bedford, Massachusetts
| | | | - Ashley Drews
- Division of Infectious Diseases, Department of Medicine, Houston Methodist, Houston, Texas
- Houston Methodist Academic Institute, Houston, Texas
- Weill Cornell Medical College, New York, New York
| | - Karl Erlandson
- Biomedical Advanced Research and Development Authority (BARDA), Administration for Strategic Preparedness and Response, US Department of Health and Human Services, Washington, District of Columbia
| | | | | | | | - Carlene Gong
- Booz Allen Hamilton in support of BARDA, Washington, District of Columbia
| | - George Hanna
- Tunnell Government Services in support of BARDA, Princeton, New Jersey
| | - Stephen Jones
- Center for Health Data Science and Analytics, Houston Methodist, Houston, Texas
| | - Bert Lopansri
- Division of Infectious Diseases and Clinical Epidemiology, Intermountain Health, Murray, Utah
- Division of Infectious Diseases, University of Utah School of Medicine, Salt Lake City
| | - James Musser
- Laboratory of Molecular and Translational Human Infectious Disease Research, Center for Infectious Diseases, Department of Pathology and Genomic Medicine, Houston Methodist Research Institute and Houston Methodist Hospital, Houston, Texas
- Department of Pathology and Laboratory Medicine, Weill Cornell Medical College, New York, New York
- Department of Microbiology and Immunology, Weill Cornell Medical College, New York, New York
| | - John O'Horo
- Center for Individualized Medicine-Mayo Clinic Research, Rochester, Minnesota
| | - Steven Piantadosi
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Bobbi Pritt
- Center for Individualized Medicine-Mayo Clinic Research, Rochester, Minnesota
| | - Raymund R Razonable
- Center for Individualized Medicine-Mayo Clinic Research, Rochester, Minnesota
| | | | - Suzanne Sandmeyer
- Department of Biological Chemistry, School of Medicine, University of California, Irvine
- Department of Microbiology and Molecular Genetics, School of Medicine, University of California, Irvine
| | - David Stein
- The MITRE Corporation, Bedford, Massachusetts
| | - Farhaan Vahidy
- Center for Health Data Science and Analytics, Houston Methodist, Houston, Texas
- Department of Neurosurgery, Houston Methodist, Houston, Texas
- Department of Population Health Science, Weill Cornell Medical College, New York, New York
| | - Brandon Webb
- Division of Infectious Diseases and Clinical Epidemiology, Intermountain Health, Murray, Utah
- Division of Infectious Diseases, University of Utah School of Medicine, Salt Lake City
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Barrera-Oro J, Liu TY, Gorden E, Kucherlapati R, Shao C, Tischfield JA. Role of the mismatch repair gene, Msh6, in suppressing genome instability and radiation-induced mutations. Mutat Res 2008; 642:74-9. [PMID: 18538799 DOI: 10.1016/j.mrfmmm.2008.04.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2008] [Revised: 04/18/2008] [Accepted: 04/21/2008] [Indexed: 11/26/2022]
Abstract
Mismatch repair (MMR) is critical for preserving genomic integrity. Failure of this system can accelerate somatic mutation and increase the risk of developing cancer. MSH6, in complex with MSH2, is the MMR protein that mediates DNA repair through the recognition of 1- and 2-bp mismatches. To evaluate the effects of MSH6 deficiency on genomic stability we compared the frequency of in vivo loss of heterozygosity (LOH) between MSH6-proficient and deficient, 129S2xC57BL/6 F1 hybrid mice that were heterozygous for our reporter gene Aprt. We recovered mutant cells that had functionally lost APRT protein activity and categorized the spectrum of mutations responsible for the LOH events. We also measured the mutant frequency at the X-linked gene, Hprt, as a second reporter for point mutation. In Msh6-/-Aprt+/- mice, mutation frequency at Aprt was elevated in both T cells and fibroblasts by 2.5-fold and 5.7-fold, respectively, over Msh6+/+Aprt+/- littermate controls. While a modest increase in mitotic recombination (MR) was observed in MSH6-deficient fibroblasts compared to wild type controls, point mutation was the predominant mechanism leading to APRT deficiency in both cell types. Base substitution, consisting of multiple types of transitions, accounted for all of the point mutations identified within the Aprt coding region. We also assessed the role of MSH6 in preventing mutations caused by a common environmental mutagen, ionizing radiation (IR). In Msh6-/-Aprt+/- mice, 4Gy of X-irradiation induced a significant increase in point mutations at both Aprt and Hprt in T cells, but not in fibroblasts. These findings indicate that MutS alpha reduces spontaneous and IR-induced mutation in a cell type-dependant manner.
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Affiliation(s)
- Julio Barrera-Oro
- Department of Genetics, Rutgers, The State University of New Jersey, Piscataway, NJ 08854, USA
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