Early Immunotherapy and Longer Corticosteroid Treatment Are Associated With Lower Risk of Relapsing Disease Course in Pediatric MOGAD

BACKGROUND AND OBJECTIVES

We sought to identify early factors associated with relapse and outcome in paediatric-onset myelin oligodendrocyte glycoprotein antibody-associated disorders (MOGAD).

METHODS

In a multicenter retrospective cohort of pediatric MOGAD (≤18 years), onset features and treatment were compared in patients with monophasic vs relapsing disease (including cases with follow-up ≥12 months after onset or relapse at any time) and in patients with final Expanded Disability Status Scale (EDSS) 0 vs ≥1 at last follow-up (including cases with follow-up >3 months after last event or EDSS0 at any time). Multivariable logistic regression models were used to evaluate factors associated with relapsing disease course and EDSS ≥ 1 at final follow-up.

RESULTS

Seventy-five children were included (median onset age 7 years; median 30 months of follow-up). Presentation with acute disseminated encephalomyelitis was more frequent in children aged 8 years or younger (66.7%, 28/42) than in older patients (30.3%, 10/33) (p = 0.002), whereas presentation with optic neuritis was more common in children older than 8 years (57.6%, 19/33) than in younger patients (21.4%, 9/42) (p = 0.001). 40.0% (26/65) of patients relapsed. Time to first relapse was longer in children aged 8 years or younger than in older patients (median 18 vs 4 months) (p = 0.013). Factors at first event independently associated with lower risk of relapsing disease course were immunotherapy <7 days from onset (6.7-fold reduced odds of relapsing course, OR 0.15, 95% CI 0.03-0.61, p = 0.009), corticosteroid treatment for ≥5 weeks (6.7-fold reduced odds of relapse, OR 0.15, 95% CI 0.03-0.80, p = 0.026), and abnormal optic nerves on onset MRI (12.5-fold reduced odds of relapse, OR 0.08, 95% CI 0.01-0.50, p = 0.007). 21.1% (15/71) had EDSS ≥ 1 at final follow-up. Patients with a relapsing course had a higher proportion of final EDSS ≥ 1 (37.5%, 9/24) than children with monophasic disease (12.8%, 5/39) (p = 0.022, univariate analysis). Each 1-point increment in worst EDSS at onset was independently associated with 6.7-fold increased odds of final EDSS ≥ 1 (OR 6.65, 95% CI 1.33-33.26, p = 0.021).

DISCUSSION

At first attack of pediatric MOGAD, early immunotherapy, longer duration of corticosteroid treatment, and abnormal optic nerves on MRI seem associated with lower risk of relapse, whereas higher disease severity is associated with greater risk of final disability (EDSS ≥ 1).

KETASER01 protocol: What went right and what went wrong

Objective

To discuss the results of the KETASER01 trial and the reasons for its failure, particularly in view of future studies.

Methods

KETASER01 is a multicenter, randomized, controlled, open‐label, sequentially designed, non‐profit Italian study that aimed to assess the efficacy of ketamine compared with conventional anesthetics in the treatment of refractory convulsive status epilepticus (RCSE) in children.

Results

During the 5‐year recruitment phase, a total of 76 RCSEs treated with third‐line therapy were observed in five of the 10 participating Centers; only 10 individuals (five for each study arm; five females, mean age 6.5 ± 6.3 years) were enrolled in the KETASER01 study. Two of the five patients (40%) in the experimental arm were successfully treated with ketamine and two of the five (40%) children in the control arm, where successfully treated with thiopental. In the remaining six (60%) enrolled patients, RCSE was not controlled by the randomized anesthetic(s).

Significance

The KETASER01 study was prematurely halted due to low eligibility of patients and no successful recruitment. No conclusions can be drawn regarding the objectives of the study. Here, we discuss the KETASER01 results and critically analyze the reasons for its failure in view of future trials.

From bench to bedside: in vitro and in vivo evaluation of a neonate-focused nebulized surfactant delivery strategy

Background

Non-invasive delivery of nebulized surfactant has been a neonatology long-pursued goal. Nevertheless, the clinical efficacy of nebulized surfactant remains inconclusive, in part, due to the great technical challenges of depositing nebulized drugs in the lungs of preterm infants. The aim of this study was to investigate the feasibility of delivering nebulized surfactant (poractant alfa) in vitro and in vivo with an adapted, neonate-tailored aerosol delivery strategy.

Methods

Particle size distribution of undiluted poractant alfa aerosols generated by a customized eFlow-Neos nebulizer system was determined by laser diffraction. The theoretical nebulized surfactant lung dose was estimated in vitro in a clinical setting replica including a neonatal continuous positive airway pressure (CPAP) circuit, a cast of the upper airways of a preterm neonate, and a breath simulator programmed with the tidal breathing pattern of an infant with mild respiratory distress syndrome (RDS). A dose-response study with nebulized surfactant covering the 100–600 mg/kg nominal dose-range was conducted in RDS-modelling, lung-lavaged spontaneously-breathing rabbits managed with nasal CPAP. The effects of nebulized poractant alfa on arterial gas exchange and lung mechanics were assessed. Exogenous alveolar disaturated-phosphatidylcholine (DSPC) in the lungs was measured as a proxy of surfactant deposition efficacy.

Results

Laser diffraction studies demonstrated suitable aerosol characteristics for inhalation (mass median diameter, MMD = 3 μm). The mean surfactant lung dose determined in vitro was 13.7% ± 4.0 of the 200 mg/kg nominal dose. Nebulized surfactant delivered to spontaneously-breathing rabbits during nasal CPAP significantly improved arterial oxygenation compared to animals receiving CPAP only. Particularly, the groups of animals treated with 200 mg/kg and 400 mg/kg of nebulized poractant alfa achieved an equivalent pulmonary response in terms of oxygenation and lung mechanics as the group of animals treated with instilled surfactant (200 mg/kg).

Conclusions

The customized eFlow-Neos vibrating-membrane nebulizer system efficiently generated respirable aerosols of undiluted poractant alfa. Nebulized surfactant delivered at doses of 200 mg/kg and 400 mg/kg elicited a pulmonary response equivalent to that observed after treatment with an intratracheal surfactant bolus of 200 mg/kg. This bench-characterized nebulized surfactant delivery strategy is now under evaluation in Phase II clinical trial (EUDRACT No.:2016–004547-36).

Electronic supplementary material

The online version of this article (10.1186/s12931-019-1096-9) contains supplementary material, which is available to authorized users.

Spring diet of the pine marten in Sardinia, Italy

Knowledge of a carnivore’s foraging behaviour is essential to understand its ecology. The pine marten Martes martes is commonly defined as an opportunistic generalist predator since its diet in Europe includes mammals, fruits, birds and invertebrates. Based on faecal analyses, we evaluated spring feeding habits and trophic niche breadth of the pine marten in a Mediterranean landscape on the island of Sardinia (Central Italy). The most important source of food for the pine marten was small mammals (mainly Apodemus sylvaticus, Mus musculus and Eliomys quercinus), accounting for 52% of the percent mean volume. Important secondary foods were invertebrates (mainly beetles and insect larvae) and birds (almost exclusively passerines), whereas large mammals, lagomorphs, reptiles and fruits made little contribution to the diet. The diet composition and the Levins’ index value suggest that the pine marten in Sardinia behaves as a facultative specialist predator, with a specialization towards small mammals.

Numerical simulations of the Richtmyer-Meshkov instability in solid-vacuum interfaces using calibrated plasticity laws

The Richtmyer-Meshkov instability of interfaces separating elastic-plastic materials from vacuum (heavy-light configuration) is studied by means of computational techniques. A fully Eulerian multimaterial algorithm that solves consistently the Euler equations and the time evolution of the deformations in the material is applied to three distinct materials (copper, aluminum, and stainless steel). If a perfectly plastic constitutive relation is considered, an empirical law is computed that relates the long-term perturbation amplitude of the interface, its maximum growth rate, the initial density, and the yield stress of the material. It is shown that this linear relation can be extended to materials that follow more complex plastic behavior which can account for rate dependency, hardening, and thermal softening, and to situations in which small-perturbation theory is no longer valid. In effect, the yield stress computed from measurements of the long-term amplitude and maximum growth rate closely matches the von Mises stress found at the interface of solid materials for a wide range of cases with different initial parameters.

Evaluation of Vickers hardness and depth of cure of six composite resins photo-activated with different polymerization modes

Aim:

The current in vitro study evaluated Vickers hardness (VK) and depth of cure (hardness ratio) of six resin composites, polymerized with a light-emitting diode (LED) curing unit by different polymerization modes: Standard 20 s, Standard 40 s, Soft-start 40 s.

Materials and Methods:

Six resin composites were selected for the present study: three microhybrid (Esthet.X HD, Amaris, Filtek Silorane), two nanohybrid (Grandio, Ceram.X mono) and one nanofilled (Filtek Supreme XT). The VK of the surface was determined with a microhardness tester using a Vickers diamond indenter and a 200 g load applied for 15 seconds. The mean VK and hardness ratio of the specimens were calculated using the formula: hardness ratio = VK of bottom surface / VK of top surface.

Results:

For all the materials tested and with all the polymerization modes, hardness ratio was higher than the minimum value indicated in literature in order to consider the bottom surface as adequately cured (0.80). Curing time did not affect hardness ratio values for Filtek Silorane, Grandio and Filtek Supreme XT.

Conclusion:

The effectiveness of cure at the top and bottom surface was not affected by Soft-start polymerization mode.

Converging shocks in elastic-plastic solids

We present an approximate description of the behavior of an elastic-plastic material processed by a cylindrically or spherically symmetric converging shock, following Whitham's shock dynamics theory. Originally applied with success to various gas dynamics problems, this theory is presently derived for solid media, in both elastic and plastic regimes. The exact solutions of the shock dynamics equations obtained reproduce well the results obtained by high-resolution numerical simulations. The examined constitutive laws share a compressible neo-Hookean structure for the internal energy e=e(s)(I(1))+e(h)(ρ,ς), where e(s) accounts for shear through the first invariant of the Cauchy-Green tensor, and e(h) represents the hydrostatic contribution as a function of the density ρ and entropy ς. In the strong-shock limit, reached as the shock approaches the axis or origin r=0, we show that compression effects are dominant over shear deformations. For an isothermal constitutive law, i.e., e(h)=e(h)(ρ), with a power-law dependence e(h) is proportional to ρ(α), shock dynamics predicts that for a converging shock located at r=R(t) at time t, the Mach number increases as M is proportional to [log(1/R)](α), independently of the space index s, where s=2 in cylindrical geometry and 3 in spherical geometry. An alternative isothermal constitutive law with p(ρ) of the arctanh type, which enforces a finite density in the strong-shock limit, leads to M is proportional to R(-(s-1)) for strong shocks. A nonisothermal constitutive law, whose hydrostatic part e(h) is that of an ideal gas, is also tested, recovering the strong-shock limit M is proportional to R(-(s-1)/n(γ)) originally derived by Whitham for perfect gases, where γ is inherently related to the maximum compression ratio that the material can reach, (γ+1)/(γ-1). From these strong-shock limits, we also estimate analytically the density, radial velocity, pressure, and sound speed immediately behind the shock. While the hydrostatic part of the energy essentially commands the strong-shock behavior, the shear modulus and yield stress modify the compression ratio and velocity of the shock far from the axis or origin. A characterization of the elastic-plastic transition in converging shocks, which involves an elastic precursor and a plastic compression region, is finally exposed.

Dielectrophoretic trapping in microwells for manipulation of single cells and small aggregates of particles

In this work we present a novel concept of active microwells based on cylindrical wells able to vertically trap and control single particles by means of negative dielectrophoresis. The device is fabricated by drilling through holes on a polyimide substrate with copper-gold or aluminum metals, forming three annular electrodes within the well. A channel under the device provides a fluid flow filling the microwell by capillarity. Particles are delivered from the top by a microdispenser and applying sinusoidal signals to the electrodes at frequencies ranging from 100kHz to 1.5MHz and amplitudes between 2V and 7V they are successfully trapped and levitated at the level of the central electrode in the middle of microwells with a diameter of 125mum. By changing signal phases, other configurations are also enabled to load particles in the well or eject them from the bottom. The extension to an array of microwells is presented and design rules are described for routing electrode connections and setting signal parameters. K562 cells cultured with Ara-C 1000nM were successfully trapped and controlled in physiological media. Polystyrene beads were also levitated in water and were used for experimental measurements on minimum amplitudes and phase differences in the signals required to levitate beads, confirming the results obtained by simulation.