Pediatric diabetes mellitus hospitalizations and COVID-19 pandemic response measures

AIMS

In the United States, evidence suggests that during the COVID-19 pandemic, admissions of patients with diabetes mellitus (DM) have increased. This study assessed hospital admission rates for pediatric type 1 (T1DM) and type 2 (T2DM) diabetes mellitus during 2019-2021, and the potential influence of the timing of various pandemic response measures.

METHODS

Retrospective chart reviews were conducted of 854 T1DM and 135 T2DM hospital admissions between January 2019 and December 2021 in patients < 20 years old to collect demographic data, admission type, body mass index (BMI), and area deprivation index (ADI, a measure of socioeconomic vulnerability). Patients were divided into three cohorts based on their admission year: 2019 (Pre-pandemic), 2020 (Pandemic, Pre-vaccine), and 2021 (Pandemic, Post-vaccine). Admissions were categorized within each cohort by diagnosis (T1DM or T2DM) and clinical presentation (new onset, diabetic ketoacidosis: DKA). Cohorts were compared using an independent samples t-test for continuous variables or a chi-square test for categorical variables.

RESULTS

The incidence of T2DM hospitalizations tripled during the pandemic, increasing from 18 in 2019 (Pre-pandemic), to 55 in 2020 (Pandemic, Pre-vaccine), and 62 in 2021 (Pandemic, Post-vaccine). The rate of patients presenting with DKA was 15.4 % (95 % CI: 4 %-26.9 %) higher in 2020 (Pandemic, Pre-vaccine) among patients with new-onset T1DM (72/139 vs. 52/143), and 22.5 % (95 % CI: 9.6 %-35.4 %) higher in 2020 (Pandemic, Pre-vaccine) among T2DM patients (9/40 vs. 0/14). This increased rate of new onset T2DM significantly correlated with younger age (P = 0.046) and higher ADI score (P = 0.017), but not with BMI.

CONCLUSION

The incidence of T1DM hospitalizations did not increase during the pandemic; however, they tripled for T2DM patients. All new onset DM pediatric patients during the pandemic were more likely to present in DKA. Patients admitted with new onset T2DM were socioeconomically more vulnerable. For T1DM, the peak of local pediatric diabetes admissions in 2020 occurred slightly later coinciding with the reopening of primary care physicians (PCP) offices and schools.

Improving blood product management in placenta accreta patients with severe bleeding: institutional experience

BACKGROUND

Placenta accrete spectrum (PAS) is a significant risk factor for postpartum hemorrhage and effective blood product management is critical in ensuring patient safety. In PAS patients undergoing cesarean section (CS) blood transfusion management guided by the combined clinical experience of the anesthesiologist and surgeon with point-of-care coagulation testing appears safe and effective. We describe and evaluate our experience and identify potential areas for improvement with blood product management in this patient population.

METHODS

A retrospective chart review of peri-operative demographic, anesthetic, and obstetric data was conducted for all patients with PAS undergoing CS between 2012 and 2018 at our center. To facilitate a practical evaluation of blood product management, we divided patients into two groups based on the severity of bleeding.

RESULTS

A total of 221 parturients with PAS underwent CS, with 133 in group 1 requiring excessive amounts of transfusion and 88 in group 2 requiring management similar to other uncomplicated CS cases. There were no deaths or instances of disseminated intravascular coagulation, and intensive care unit admission occurred in five cases (2.2%). Patients in group 1 had higher mean nadir values of intra-operative hemoglobin and platelet count. We observed a high rate of missing data for peri-operative measurement of lactate and fibrinogen, PAS grade documentation, and temperature monitoring.

CONCLUSION

Given no significant morbidity or mortality, clinical judgment in experienced centers appears safe for the management of PAS patients undergoing CS. The adoption of an institutional protocol and point-of-care coagulation testing could decrease over-transfusion and associated complications.

Impact of "early intervention" parent workshops on outcomes for caregivers of children with neurodisabilities: a mixed-methods study

PURPOSE

This study explored the feasibility, impact and parent experiences of ENVISAGE (ENabling VISions And Growing Expectations)-Families, a parent-researcher co-designed and co-led program for parents/caregivers raising children with early-onset neurodisabilities.

METHODS

Parents/caregivers of a child with a neurodisability aged ≤6 years, recruited in Australia and Canada, participated in five weekly online workshops with other parents. Self-report measures were collected at baseline, immediately after, and 3 months post-ENVISAGE-Families; interviews were done following program completion. Quantitative data were analyzed with generalized estimating equations and qualitative data using interpretive description methodology.

RESULTS

Sixty-five parents (86% mothers) were recruited and 60 (92%) completed the program. Strong evidence was found of effects on family empowerment and parent confidence (all p ≤ 0.05 after the program and maintained at 3-month follow-up). The ENVISAGE-Families program was relevant to parents' needs for: information, connection, support, wellbeing, and preparing for the future. Participants experienced opportunities to reflect on and/or validate their perspectives of disability and development, and how these perspectives related to themselves, their children and family, and their service providers.

CONCLUSIONS

ENVISAGE was feasible and acceptable for parent/caregivers. The program inspired parents to think, feel and do things differently with their child, family and the people who work with them.Implications for rehabilitationENVISAGE (ENabling VISions And Growing Expectations)-Families is a co-designed, validated parent/researcher "early intervention and orientation" program for caregivers raising a child with neurodevelopmental disabilities (NDDs).ENVISAGE-Families empowered parents' strengths-based approaches to their child, family, disability, and parenting.ENVISAGE-Families increased caregivers' confidence in parenting children with NDD's and provided them tools to support connection, collaboration, and wellbeing.Raising children with NDD can have a profound impact on caregivers, who can benefit from strengths-based, future focused supports early in their parenting experience.

Association between body mass and hypotension in dogs under general anaesthesia

OBJECTIVES

To investigate the association between body mass and hypotension during general anaesthesia in dogs undergoing surgical and diagnostic procedures within a referral hospital.

MATERIALS AND METHODS

Retrospective evaluation of the anaesthetic records of 1789 dogs was performed. Data on signalment, anaesthetic protocol and physiological variables, including mean arterial pressure, were collected. A multivariable generalised linear model was used to identify associations between explanatory variables, including body mass, and hypotension.

RESULTS

In the population studied, increasing body mass (per 10 kg) was significantly associated with decreasing odds of hypotension (odds ratio 0.68; 95% confidence interval: 0.60 to 0.77). Additional variables associated with a decreased odds of hypotension were pre-anaesthetic medication with alpha-2 agonists (odds ratio 0.63; 95% confidence interval 0.48 to 0.82) and increased body temperature (per 1°C) during general anaesthesia (odds ratio 0.77; 95% confidence interval 0.67 to 0.88). Brachycephaly (odds ratio 1.72; 95% confidence interval 1.25 to 2.38), ASA physical status classification >3 (odds ratio 2.03; 95% confidence interval 1.16 to 3.56), undergoing a surgical procedure (versus diagnostic) (odds ratio 1.57; 95% confidence interval 1.10 to 2.23) and bradycardia (odds ratio 1.37; 95% confidence interval 1.05 to 1.80) were independently associated with increased odds of hypotension.

CLINICAL SIGNIFICANCE

Dogs of lower body mass and brachycephalic breeds may be at higher risk of hypotension during general anaesthesia or alternatively represent subpopulations in which accurate blood pressure measurement presents a greater challenge. Monitoring blood pressure accurately in these groups requires particular attention and provisions for treating hypotension should be readily accessible.

The characteristics of drowning among different types of international visitors to Australia and how this contributes to their drowning risk

OBJECTIVE

Australia is a popular destination for international visitors. This study reviews international visitor drowning deaths in Australia and analyses drowning by visitor type.

METHODS

A total population retrospective study exploring drowning deaths of international visitors was conducted between 2008 and 2018. Data were extracted from the Royal Life Saving National Fatal Drowning Database and categorised into four subgroups: overseas tourists, international students, working holiday makers and work-related visitors. Descriptive statistics, non-parametric tests and relative risk (RR) were calculated.

RESULTS

In total, 201 international visitors drowned in Australia, 7% of all drowning deaths; a crude drowning rate of 0.27/100,000 visitors versus 0.95/100,000 for residents (RR=0.19 [95% CI: 0.16-0.22]). Most deaths were males (79%) and people aged 18-34 years (50%). Visitors frequently drowned at beaches (33%), and when swimming (41%). Thirty-five percent recorded a pre-existing medical condition. Overseas tourists on holiday were the most likely to drown compared to other subgroups.

CONCLUSION

International visitors represent a small but increasing proportion of people drowning in Australia. The circumstances of which visitors drown vary by travel purpose, age, country of origin, location of drowning and activity.

IMPLICATIONS FOR PUBLIC HEALTH

International visitors have unique safety needs, requiring tailored prevention based on the purpose of travel and country of origin.

HOPE & DREAM: A Two-Clinic NICU Follow-Up Model

The natural extension of inpatient-focused neonatal neurocritical care (NNCC) programs is the evaluation of long-term neurodevelopmental outcomes in the same patient population. A dedicated and collaborative team of neonatologists, neonatal neurologists, neuropsychologists, neurosurgeons, physical medicine and rehabilitation physicians, and psychologists are necessary to provide personalized medicine, developmental assessments, and parental education for NNCC graduates. To achieve this goal, we devised a two-clinic follow-up model at Children's Wisconsin: HOPE clinic (Healthy Outcomes Post-ICU Engagement) and DREAM clinic (Developmentally Ready: Engagement for Achievement of Milestones). Those infants with significant neurologic diagnoses attend DREAM clinic, while all other high-risk NICU infants are seen in the HOPE clinic. These clinic models allow for a targeted approach to post-NICU care which has improved family engagement and perceptions of value.

Determining the Impact of Heatwaves on Emergency Ambulance Calls in Queensland: A Retrospective Population-Based Study

Heatwaves are a significant and growing threat to the health and well-being of the residents of Queensland, Australia. This threat is increasing due to climate change. Excess heat increases the demand for health services, including ambulance calls, and the purpose of this study was to explore this impact across Queensland. A state-wide retrospective analysis of heatwaves and emergency 'Triple Zero' (000) calls to Queensland Ambulance (QAS) from 2010-2019 was undertaken. Call data from the QAS and heatwave data from the Bureau of Meteorology were analysed using a case-crossover approach at the postcode level. Ambulance calls increased by 12.68% during heatwaves. The effect was greatest during low-severity heatwaves (22.16%), followed by severe (14.32%) and extreme heatwaves (1.16%). The impact varied by rurality, with those living in very remote areas and major cities most impacted, along with those of low and middle socioeconomic status during low and severe intensity heat events. Lag effects post-heatwave continued for at least 10 days. Heatwaves significantly increase ambulance call centre workload, so ambulance services must actively prepare resources and personnel to address increases in heatwave frequency, duration, and severity. Communities must be informed of the risks of heatwaves at all severities, particularly low severity, and the sustained risks in the days following a heat event.

Heatwaves and mortality in Queensland 2010-2019: implications for a homogenous state-wide approach

Heatwaves are a significant cause of adverse health outcomes and mortality in Australia, worsening with climate change. In Queensland, the northeastern-most state, little is known about the impact of heatwaves outside of the capital city of Brisbane. This study aims to explore the impact of heatwaves on mortality across various demographic and environmental conditions within Queensland from 2010 to 2019. The Excess Heat Factor was used to indicate heatwave periods at the Statistical Area 2 (SA2) level. Registered deaths data from the Australian Bureau of Statistics and heatwave data from the Bureau of Meteorology were matched using a case-crossover approach. Relative risk and 95% confidence intervals were calculated across years, regions, age, sex, rurality, socioeconomic status, and cause of death. Heatwaves were associated with a 5% increase in all-cause mortality compared to deaths on non-heatwave days, with variability across the state. The risk of death on a heatwave day versus a non-heatwave day varied by heatwave severity. Individuals living in urban centers, the elderly, and those living in regions of lower socioeconomic status were most impacted by heatwave mortality. The relative risk of dying from neoplasms, nervous system conditions, respiratory conditions, and mental and behavioral conditions increased during heatwaves. As heatwaves increase in Queensland due to climate change, understanding the impact of heatwaves on mortality across Queensland is important to tailor public health messages. There is considerable variability across communities, demographic groups, and medical conditions, and as such messages need to be tailored to risk.

Impact of transcatheter mitral valve edge-to-edge repair on atrial fibrillation burden: Insights from a multicenter cohort

BACKGROUND

Patients with significant mitralregurgitation (MR) often experience atrial fibrillation (AF). The effects of transcatheter edge-to-edge repair (TEER) for MR on AF burden is unknown.

METHODS

Patients who underwent TEER atthree institutions who also had a cardiac implantable electronic device with aright atrial lead were retrospectively identified. In patients with baseline AF, device data onAF burden and echocardiographic changes were recorded at baseline and 3- and 12-month follow up time points when available. Data is expressed as number (%) and median (interquartile range), withpaired values analyzed using the Wilcoxon signed-rank test.

RESULTS

Overall 66 patients wereidentified, of whom 54 (82%) had baseline data on AF available for review. Of these, 18 (33%) had a baseline burden ofAF (median burden 100% [54-100%]). Patients were 77 (71-83) years old, 10 (56%) male, 14 (78%) White, and 3 (17%) Black. A significant reduction in AF burdenwas observed at 3 months (11 patients, p = 0.03) which did not retainsignificance at 12 months (8 patients, p = 0.69). Indexed maximal left atrial volumes did not significantly change inthose with paired studies available (p > 0.35 for both time points).

CONCLUSIONS

In this multicenter cohort, one thirdof patients with severe MR undergoing TEER had an AF burden at baseline, whichwas found to be significantly lower at 3 month follow up. Further investigation is needed to confirm thefindings of this small cohort and determine its effects on downstream sequelaeof AF.

Exercise, diet, and sleep habits of nurses working full-time during the COVID-19 pandemic: An observational study

BACKGROUND

Healthy diet, exercise, and sleep practices may mitigate stress and prevent illness. However, lifestyle behaviors of acute care nurses working during stressful COVID-19 surges are unclear.

PURPOSE

To quantify sleep, diet, and exercise practices of 12-hour acute care nurses working day or night shift during COVID-19-related surges.

METHODS

Nurses across 10 hospitals in the United States wore wrist actigraphs and pedometers to quantify sleep and steps and completed electronic diaries documenting diet over 7-days.

FINDINGS

Participant average sleep quantity did not meet national recommendations; night shift nurses (n = 23) slept significantly less before on-duty days when compared to day shift nurses (n = 34). Proportionally more night shift nurses did not meet daily step recommendations. Diet quality was low on average among participants.

DISCUSSION

Nurses, especially those on night shift, may require resources to support healthy sleep hygiene, physical activity practices, and diet quality to mitigate stressful work environments.

Hemodynamic response and safety of vasodilator stress cardiovascular magnetic resonance in patients with permanent pacemakers or implantable cardioverter-defibrillators

INTRODUCTION

Vasodilator stress cardiovascular magnetic resonance (CMR) is a powerful diagnostic modality, but data toward its use in patients with permanent pacemakers (PPMs) or implantable cardioverter-defibrillators (ICDs) is limited.

METHODS AND RESULTS

Patients with ICDs (>1% pacing) or PPMs who underwent regadenoson single photon emission computed tomography (SPECT) and all patients with ICDs or PPMs who underwent stress CMR were retrospectively identified. SPECT tests were analyzed for hemodynamic responses and new pacing requirements; CMR studies were examined for safety, device characteristics and programming, hemodynamic responses, and image quality. Changes from baseline were evaluated with the Related-Samples Wilcoxon Signed Rank Test. Of 67 patients (median age 65 [IQR 58-72] years, 31 [46%] female, 31 [46%] Black), 47 underwent SPECT and 20 CMR. With regadenoson SPECT, 89% of patients experienced tachycardic responses above resting heart rates (+19 [13-32] beats per minute, p < .01). During stress CMR, 10 (50%) devices were asynchronously paced approximately 10 beats per minute above resting rates, and the remaining were temporarily deactivated. Those with asynchronous pacing had no changes in heart rates, whereas patients with deactivated devices had near uniform heart rate accelerations. Image quality was diagnostic in the majority of stress CMR sequences, with nonconditional ICDs contributing 40 of 57 (70%) of nondiagnostic segments.

CONCLUSION

This data supports the safety of vasodilator stress CMR with promising diagnostic quality images in patients with CMR conditional ICDs and PPMs. Despite a near uniform tachycardic response to regadenoson in the SPECT environment, high rates of asynchronous pacing during vasodilator stress CMR did not result in competitive pacing or adverse arrhythmic events. Further studies are needed to validate these findings and confirm the diagnostic and prognostic performance of stress CMR in these individuals.

Women's Perceptions of HIV- and Sexuality-Related Stigma in Relation to PrEP: Qualitative Findings from the Masibambane Study, Durban, South Africa

Daily oral pre-exposure prophylaxis (PrEP) offers effective HIV prevention. In South Africa, PrEP is publicly available, but use among young women remains low. We explored young women's perceptions of PrEP to inform a gender-focused intervention to promote PrEP uptake. Six focus group discussions and eight in-depth interviews exploring perceptions of PrEP were conducted with forty-six women not using PrEP, ages 18-25, from central Durban. Data were thematically analyzed using a team-based consensus approach. The study was conducted among likely PrEP users: women were highly-educated, with 84.8% enrolled in post-secondary education. Qualitative data revealed intersecting social stigmas related to HIV and women's sexuality. Women feared that daily PrEP pills would be confused with anti-retroviral treatment, creating vulnerability to misplaced HIV stigma. Women also anticipated that taking PrEP could expose them to assumptions of promiscuity from the community. To address these anticipated community-level reactions, women suggested community-facing interventions to reduce the burden on young women considering PrEP. Concerns around PrEP use in this group of urban, educated women reflects layered stigmas that may inhibit future PrEP use. Stigma-reducing strategies, such as media campaigns and educational interventions directed at communities who could benefit from PrEP, should re-frame PrEP as an empowering and responsible choice for young women.

Assessing the validity of mobile device data for estimating visitor demographics and visitation patterns in Yellowstone National Park

Monitoring visitor demographics and temporal visitation patterns can help national park managers understand their visitors and allocate resources more effectively. Traditional approaches, such as visitor surveys or vehicle counts, are limited by time, space, labor, and financial resources. More recently, mobile device data have been adopted for monitoring visitors in park-related or tourism research. However, few studies validated mobile device data with traditional visitor surveys or count data. Combining mobile device data with the American Community Survey (ACS), this study assessed mobile device data's validity in a national park context with three approaches: Points of Interest (POIs), visitor demographics, and temporal visitation patterns. The results revealed that only half of the POIs inside Yellowstone National Park are valid. Compared to traditional visitor surveys, mobile device data are limited due to platform bias and the exclusion of international visitors, resulting in discrepancies in visitor demographics, such as education and income levels. Conversely, mobile device data have strong correlations with count data regarding monthly and daily visitation patterns. The results suggest that with careful consideration, mobile device data can serve as an additional and complementary source of information to traditional survey data for understanding visitor demographics and temporal visitation patterns.

The Effects of Chronic Variable Stress and Photoperiod Alteration on the Hypothalamic-Pituitary-Adrenal Axis Response and Behavior of Mice

The hypothalamic-pituitary-adrenal (HPA) axis mediates the physiological response to stressors and also synchronizes different physiological systems to environmental cues. Changes in day length (i.e., photoperiod) as well as chronic exposure to stressors are known to impact the HPA axis activity regulating the levels of glucocorticoid hormones. Over-exposure to inappropriate levels of glucocorticoids has been implicated in increased disease risk. In the present study, we examined the impact of chronic stress, using a chronic variable stress (CVS) paradigm, in combination with changes in photoperiod on physiological and behavioral measures, as well as on the reactivity and regulation of the HPA axis, in male and female mice. Six weeks of CVS, regardless of the photoperiod condition, decreased the body weight and attenuated the HPA axis reactivity to an acute stressor in both sexes. The attenuated HPA axis reactivity observed in stressed animals was related to reduced Pro-opiomelanocortin (POMC) mRNA levels in the pituitary of females. The gene expression analyses of key regulators of the HPA axis also indicated a sex-dependent effect with opposite patterns in the pituitary and adrenal glands. CVS effects on behavior were limited and related to an anxiety-like phenotype in both sexes, regardless of photoperiod condition. Our findings highlight sex-specific differences in the HPA axis and also sex-dependent effects of CVS on physiological parameters.

Design of protein-binding proteins from the target structure alone

The design of proteins that bind to a specific site on the surface of a target protein using no information other than the three-dimensional structure of the target remains a challenge1-5. Here we describe a general solution to this problem that starts with a broad exploration of the vast space of possible binding modes to a selected region of a protein surface, and then intensifies the search in the vicinity of the most promising binding modes. We demonstrate the broad applicability of this approach through the de novo design of binding proteins to 12 diverse protein targets with different shapes and surface properties. Biophysical characterization shows that the binders, which are all smaller than 65 amino acids, are hyperstable and, following experimental optimization, bind their targets with nanomolar to picomolar affinities. We succeeded in solving crystal structures of five of the binder-target complexes, and all five closely match the corresponding computational design models. Experimental data on nearly half a million computational designs and hundreds of thousands of point mutants provide detailed feedback on the strengths and limitations of the method and of our current understanding of protein-protein interactions, and should guide improvements of both. Our approach enables the targeted design of binders to sites of interest on a wide variety of proteins for therapeutic and diagnostic applications.

Travel-weary to travel-worry: the epidemiology of injury-related traveller deaths in Australia, 2006-2017

OBJECTIVE

To explore injury deaths in international and domestic interstate travellers, together with those newly arrived to Australia.

METHODS

A population-based cohort study of all injury-related deaths between 1January 2006 and 31 December 2017 registered with Births Death and Marriages in Australia was conducted using Australian Bureau of Statistics' (ABS) Cause of Death information. Population data on travellers were obtained from Tourism Research Australia.

RESULTS

There were 4,503 injury-related traveller deaths (domestic interstate:3,055; international:934; new arrivals:514). The average annual age-standardised mortality rates in domestic interstate travellers was 0.75 per 100,000, compared with 2.22 per 100,000 in international travellers. Leading causes of injury-related death were land transport incidents (n=1495, 33.2%), self-harm (n=786, 17.5%) and falls (n=513, 11.4%), with differences in mechanism by state/territory, traveller type and age group. Intentional self-harm was common amongst all visitor types, however, it was the primary cause of death in new arrivals Conclusion: Age-standardised mortality rates were almost three-fold higher in international than domestic travellers. New arrivals, international and domestic travellers have different injury profiles, and each require specific prevention strategies.

IMPLICATIONS FOR PUBLIC HEALTH

While COVID has restricted travel to and within Australia, this has provided an opportunity for exploration, reflection, and consideration of risk factors for travellers, and to develop targeted injury prevention strategies for visitor types, so travel experience can be optimised and the magnitude of harm can be reduced.

Corrigendum to: 204. Mucosal Cytokine Profiles in Children with COVID-19

[This corrects the article DOI: 10.1093/ofid/ofab466.000.].

Trends in quality of care among children with sickle cell anemia

INTRODUCTION

For decades, it has been recommended that children with sickle cell anemia (SCA) receive antibiotic prophylaxis to prevent serious infections and undergo transcranial Doppler (TCD) screening to identify those at highest risk of overt stroke. We assessed recent temporal trends in antibiotic prophylaxis prescription fills and TCD screening among children with SCA using validated quality measures.

PROCEDURE

Using validated claims-based definitions, we identified children with SCA who were enrolled in Michigan or New York State (NYS) Medicaid programs (2011-2018). Among recommended age groups, two outcomes were assessed yearly: (a) filling of ≥300 days of antibiotics, and (b) receipt of greater than or equal to one TCD. The proportion of children with each outcome was calculated by state. Temporal trends in each preventive service were assessed using generalized linear models.

RESULTS

A total of 1784 children were eligible for antibiotic prophylaxis (Michigan: 384; NYS: 1400), contributing 3322 person-years. Annual rates of filling ≥300 days of antibiotics ranged from 16% to 22% and were similar by state. There was no change in rates of antibiotic filling over time in Michigan (p-value: .10), but there was a decrease in NYS (p-value: .02). A total of 3439 children with SCA were eligible for TCD screening (Michigan: 710; NYS: 2729), contributing 10,012 person-years. Annual rates of TCD screening ranged from 39% to 45%, were similar by state, and did not change over time (p-values >.05).

CONCLUSIONS

Most children with SCA do not receive recommended antibiotic prophylaxis and/or TCD screening. New, sustainable, and coordinated interventions across preventive services are urgently needed.

Collaborative study for the establishment of Human immunoglobulin for anticomplementary activity BRP replacement batches 3, 4, 5 and 6

Human immunoglobulin products are used for the treatment of a number of diseases, such as primary or secondary immunodeficiencies and autoimmune conditions due to the complete absence of antibodies or the production of defective immunoglobulins. Quality control of human immunoglobulin products is essential to ensure therapeutic functionality and safety. This includes testing for Fc function and anticomplementary activity (ACA), as well as verification of appropriate molecular size distribution using size-exclusion chromatography as prescribed in the European Pharmacopoeia (Ph. Eur.) monographs 0338, 0918, 2788 and 1928. To this end, specific biological reference preparations (BRPs) must be used. Stocks of the Ph. Eur. Human immunoglobulin for anticomplementary activity BRP were running low and therefore a collaborative study was run by the European Directorate for the Quality of Medicines & HealthCare (EDQM), under the aegis of the Biological Standardisation Programme, to calibrate replacement batches. Six laboratories, including manufacturers and one Official Medicines Control Laboratory, took part in the study. Several batches of candidate BRPs were calibrated against Ph. Eur. Human immunoglobulin for anticomplementary activity BRP batch 2 to ensure continuity. Based on the study results, the candidate BRPs were adopted by the Ph. Eur. Commission as Ph. Eur. human immunoglobulin for anticomplementary activity BRP batch 3, 4, 5 and 6.

Parental presence at the bedside of critically ill children in the pediatric intensive care unit: A scoping review

Parental presence at the bedside (PPB) of critically ill children in the pediatric intensive care unit (PICU) is necessary for operationalizing family-centred care. Previous evidence syntheses emphasize parent-healthcare provider interactions at rounds and resuscitation; our focus is the parent-child dyad. Prior to embarking on further study, we performed a scoping review to determine the breadth and scope of the literature addressing PPB of critically ill children in the PICU. We searched five online databases (MEDLINE, EMBASE, CINAHL, Cochrane Library, and PSYCHINFO) and the grey literature to identify English and French reports from January 1960 to June 2020 addressing physical parental presence with children (birth to 18 years) in intensive care units, without limitation by methodology. Screening, reference selection, and data extraction were performed by two independent reviewers. Data were extracted into a researcher-designed tool. We identified 204 publications (81 quantitative, 68 qualitative, 22 mixed methods, and 9 descriptive case or practice change studies, and a further 24 non-study reports). PPB was directly assessed in 78 (38%) reports, and was the primary objective in 64 (31%). Amount or quality of presence was addressed by 114 reports, barriers and enablers by 152 sources, and impacts and outcomes by 134 sources. While only 6 reports were published in the first two decades of our search (1960-1980), 17 reports were published in 2019 alone. Conclusions: A relatively large body of literature exists addressing PPB of critically ill children. Separate systematic evidence syntheses to assess each element of PPB are warranted. Scoping review protocol registration: Open science framework, protocol nx6v3, registered 9-September-2019. What is Known: • Parental presence at the bedside of critically ill children must be enabled to facilitate family centeredness in care. • Systematic evidence syntheses have focused on parental presence at rounds or resuscitation, rather than with the child throughout the intensive care journey. What is New: • Many reports (n=204) address parental presence at the bedside in the pediatric intensive care unit, though most do as incidental findings • Identifies studies addressing key elements of parental presence in the PICU including barriers and enablers to, amount and quality of, and impact and outcomes of parental presence, and demonstrates trends over time and geography.

204. Mucosal Cytokine Profiles in Children with COVID-19

Background

The mechanisms associated with COVID-19 in children are not well understood. We sought to define the differences in nasopharyngeal (NP) cytokine profiles according to clinical presentation in children with COVID-19.

Methods

Single-center, prospective study in 137 children and adolescents < 21 years of age hospitalized with COVID-19, and 35 age, sex and race matched pre-pandemic (2016-2019) healthy controls. Children with COVID-19 were categorized according to their clinical presentation in: COVID-19-symptomatic; COVID-19-screening, and multisystem inflammatory syndrome (MIS-C). NP swabs were obtained within 24 hours of admission to measure SARS-CoV-2 loads by rt-PCR, and a 92-cytokine panel. Unsupervised and supervised analysis adjusted for multiple comparisons were performed.

Results

From 3/2020 to 1/2021, we enrolled 76 COVID-19-symptomatic children (3.5 [0.2-15.75] years); 45 COVID-19-screening (11.1 [4.2-16.1] years), and 16 MIS-C (11.2 [5.9-14.6] years). Median NP SARS-CoV-2 loads were higher in COVID-19-symptomatic versus screening and MIS-C (6.8 vs 3.5 vs 2.82 log₁₀ copies/mL; p< 0.001). Statistical group comparisons identified 15 cytokines that consistently differed between groups and were clustered in three functional categories: (1) antiviral/regulatory, (2) pro-inflammatory/chemotactic, and (3) a combination of (1) and (2); (Fig 1). All 15 cytokines were higher in COVID-19-symptomatic versus controls (p< 0.05). Similarly, and except for TNF, CCL3, CCL4 and CCL23, which were comparable in COVID-19-symptomatic and screening patients, the remaining cytokines were higher in symptomatic children (p< 0.05). PDL-1 (p=0.01) and CCL3 (p=0.03) were the only cytokines significantly decreased in children with MIS-C versus symptomatic COVID-19 children.

The 15 cytokines identified by multiple comparisons were correlated using Person’s in R software. Red reflects a positive correlation and blue a negative correlation with the intensity of the color indicating the strength of the association.

Conclusion

Children with symptomatic COVID-19 demonstrated higher viral loads and greater mucosal cytokines concentrations than those identified via screening, whereas in MIS-C concentrations of regulatory cytokines were decreased. Simultaneous evaluation of viral loads and mucosal immune responses using non-invasive sampling could aid with the stratification of children and adolescents with COVID-19 in the clinical setting.

Disclosures

Octavio Ramilo, MD, Adagio (Consultant)Bill & Melinda Gates Foundation (Grant/Research Support)Janssen (Grant/Research Support)Lilly (Consultant)Merck (Consultant, Grant/Research Support)NIH (Grant/Research Support)Pfizer (Consultant)SANOFI (Board Member) Asuncion Mejias, MD, PhD, MsCS, Janssen (Grant/Research Support, Advisor or Review Panel member)Merck (Grant/Research Support, Advisor or Review Panel member)Roche (Advisor or Review Panel member)Sanofi (Advisor or Review Panel member).

81. SARS-CoV-2 RNAemia and Disease Severity in Pediatric Coronavirus Disease 2019 (COVID-19)

Background

Children with COVID-19 may develop severe disease. In hospitalized adults, detection of plasma SARS-CoV-2 RNAemia ranges from 19% to 42% and has been associated with worse clinical outcomes. A similar association in children remains unexplored. We determined the frequency of SARS-CoV-2 RNAemia in children hospitalized with COVID-19 and evaluated its potential association with severe disease.

Methods

Single center prospective study that enrolled hospitalized children and adolescents ≤21 years old with COVID-19 from March 2020-April 2021 at Nationwide Children’s Hospital, Columbus, OH. Nasopharyngeal (NP) and blood samples were obtained and SARS-CoV-2 RNA was quantified using a real time PCR assay targeting the N1 gene. Pertinent demographic, clinical, laboratory, and outcome data were evaluated.

Results

We enrolled a convenience sample of 103 hospitalized children (median age, 9 years; range, 3 days-21 years) who had confirmed SARS-CoV-2 infection and both NP and blood samples obtained (Table 1). Overall, 27 (26%) patients with COVID-19 had SARS-CoV-2 RNAemia. Compared with patients who had undetectable RNAemia, those with SARS-CoV-2 RNAemia had significantly higher nasopharyngeal RNA loads (8.1 vs. 4.9 log10 copies/mL; p=0.0006), fever (78 vs 54%; p=0.02), receipt of supplemental oxygen (37% vs 14%; p=0.02), and treatment with anti-COVID-19 medications (30% vs 12%; p=0.04). In addition, patients with SARS-CoV-2 RNAemia were more likely to require intensive care (40%% vs. 20%, p= 0.04) and had longer hospitalization (2.56 vs 2.15 days; p=0.03). There were no COVID-19 related deaths.

Table 1. Demographic, clinical, laboratory and virology characteristics of study patients

Conclusion

The frequency of SARS-CoV-2 RNAemia in pediatric patients was 26% and its finding was associated with worse clinical in-hospital outcomes, similar to that reported in adults. Testing for SARS-CoV-2 RNAemia in children may help identify those who could benefit from more intensive supportive care as well as antiviral and anti-inflammatory medications.

Disclosures

Octavio Ramilo, MD, Adagio (Consultant)Bill & Melinda Gates Foundation (Grant/Research Support)Janssen (Grant/Research Support)Lilly (Consultant)Merck (Consultant, Grant/Research Support)NIH (Grant/Research Support)Pfizer (Consultant)SANOFI (Board Member) Asuncion Mejias, MD, PhD, MsCS, Janssen (Grant/Research Support, Advisor or Review Panel member)Merck (Grant/Research Support, Advisor or Review Panel member)Roche (Advisor or Review Panel member)Sanofi (Advisor or Review Panel member)

Dendritic cell vaccines targeting tumor blood vessel antigens in combination with dasatinib induce therapeutic immune responses in patients with checkpoint-refractory advanced melanoma

Background

A first-in-human, randomized pilot phase II clinical trial combining vaccines targeting overexpressed, non-mutated tumor blood vessel antigens (TBVA) and tyrosine kinase inhibitor dasatinib was conducted in human leukocyte antigen (HLA)-A2⁺ patients with advanced melanoma.

Methods

Patient monocyte-derived type-1-polarized dendritic cells were loaded with HLA-A2-presented peptides derived from TBVA (DLK1, EphA2, HBB, NRP1, RGS5, TEM1) and injected intradermally as a vaccine into the upper extremities every other week. Patients were randomized into one of two treatment arms receiving oral dasatinib (70 mg two times per day) beginning in week 5 (Arm A) or in week 1 (Arm B). Trial endpoints included T cell response to vaccine peptides (interferon-γ enzyme-linked immunosorbent spot), objective clinical response (Response Evaluation Criteria in Solid Tumors V.1.1) and exploratory tumor, blood and serum profiling of immune-associated genes/proteins.

Results

Sixteen patients with advanced-stage cutaneous (n=10), mucosal (n=1) or uveal (n=5) melanoma were accrued, 15 of whom had previously progressed on programmed cell death protein 1 (PD-1) blockade. Of 13 evaluable patients, 6 patients developed specific peripheral blood T cell responses against ≥3 vaccine-associated peptides, with further evidence of epitope spreading. All six patients with specific CD8⁺ T cell response to vaccine-targeted antigens exhibited evidence of T cell receptor (TCR) convergence in association with preferred clinical outcomes (four partial response and two stabilization of disease (SD)). Seven patients failed to respond to vaccination (one SD and six progressive disease). Patients in Arm B (immediate dasatinib) outperformed those in Arm A (delayed dasatinib) for immune response rate (IRR; 66.7% vs 28.6%), objective response rate (ORR) (66.7% vs 0%), overall survival (median 15.45 vs 3.47 months; p=0.0086) and progression-free survival (median 7.87 vs 1.97 months; p=0.063). IRR (80% vs 25%) and ORR (60% vs 12.5%) was greater for females versus male patients. Tumors in patients exhibiting response to treatment displayed (1) evidence of innate and adaptive immune-mediated inflammation and TCR convergence at baseline, (2) on-treatment transcriptional changes associated with reduced hypoxia/acidosis/glycolysis, and (3) increased inflammatory immune cell infiltration and tertiary lymphoid structure neogenesis.

Conclusions

Combined vaccination against TBVA plus dasatinib was safe and resulted in coordinating immunologic and/or objective clinical responses in 6/13 (46%) evaluable patients with melanoma, particularly those initiating treatment with both agents.

Trial registration number

NCT01876212.

Efficacy and Safety Trends with Continuous, Long-Term Crisaborole Use in Patients Aged ≥ 2 Years with Mild-to-Moderate Atopic Dermatitis

INTRODUCTION

Atopic dermatitis (AD) is a chronic inflammatory skin disease often requiring long-term treatment. Crisaborole significantly improved global AD signs and symptoms in 28-day phase 3 studies of patients aged ≥ 2 years with mild-to-moderate AD (Investigator's Static Global Assessment [ISGA] 2 or 3). A post hoc analysis of a long-term, open-label extension study was conducted to assess efficacy and safety trends of crisaborole in patients stratified by the number of initial consecutive crisaborole treatment cycles, defined as the number of treatment cycles completed before achievement of ISGA 0 (clear)/1 (almost clear).

METHODS

Patients completing phase 3 studies without drug-related safety issues that precluded further crisaborole treatment were analyzed. Patients with ISGA 0/1 at baseline (the end of a 28-day cycle) did not receive crisaborole for the next 28-day cycle (off-treatment), whereas patients with ISGA ≥ 2 received crisaborole for the next 28-day cycle (on-treatment). Patients were stratified by number of initial consecutive crisaborole treatment cycles. Efficacy was assessed by achievement and maintenance of ISGA 0/1, and safety was assessed by incidence of treatment-emergent adverse events (TEAEs) and treatment-related AEs (TRAEs).

RESULTS

Overall, 418 patients were included in exclusive cohorts based on number of consecutive on-treatment cycles (1 on-treatment cycle, n = 133; 2 consecutive on-treatment cycles, n = 106; 3 consecutive on-treatment cycles, n = 106; 4 consecutive on-treatment cycles, n = 73). After one to four initial consecutive on-treatment cycles, 77.6, 76.3, 59.4, and 43.1% of patients, respectively, achieved ISGA 0/1. Of these patients, 49.5, 37.8, 44.4, and 45.2%, respectively, maintained ISGA 0/1 at the end of a 28-day cycle off-treatment. Incidence of TRAEs was 4.5, 4.7, 3.8, and 1.4% for patients receiving one to four consecutive on-treatment cycles, respectively. One patient discontinued because of AEs.

CONCLUSION

These results support the efficacious and safe continuous, long-term use of crisaborole for the management of mild-to-moderate AD.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02118766, NCT02118792.

Early onset of pre-lethal effects of lotilaner (Credelio®) on Amblyomma americanum ticks on experimentally infested dogs

Background

The speed with which acaricides paralyze and kill ticks is relevant to impeding pathogen transmission. The objective of this study was to assess early-onset lotilaner effects on the motility and weights of Amblyomma americanum ticks collected from treated dogs.

Methods

Twelve healthy dogs were randomized between two groups to receive either lotilaner (Credelio^®) on Day 0 or to be sham treated. On Day 7, 25 male and 25 female A. americanum were placed under bandages, two on each flank of each dog. After 30 or 45 min, all unattached ticks were removed and T = 0 was set. At T = 2, 4, 8 and 24 h post attachment, 5 attached ticks removed from each bandage on each dog were weighed, assessed by blinded observers for righting ability and movement recorded.

Results

After the infestation period significantly fewer treated than control dogs had 20 ticks attached (50.0% versus 91.7%, P = 0.0015). At 24 h post attachment, mean weights of ticks from treated dogs (males 1.69 mg; females 2.72) were significantly less than ticks from controls (males 2.66 mg; females 4.67) (P_male = 0.0002; P_female < 0.0001). Mean tick weights from the treated group were significantly lower at 24 h than at earlier time points (P_male < 0.0307; P_female = 0.0021). At 4 and 8 h, significantly fewer ticks from treated (14.3%, 0.0%, respectively) than from control dogs could right (73.3%, 70.0%) (P_4h < 0.0001; P_8h = 0.0024) (at 24 h, all ticks from treated dogs were dead), and distance moved was significantly less at all time points (P_2h = 0.0413; P_4h, P_8h < 0.0001). Mean and maximum velocity of ticks from treated dogs were significantly lower, relative to controls, at 4 and 8 h (P ≤ 0.0001). Within the treated group, collected ticks had significantly lower mean and maximum velocities at 4 and 8 h compared to 2 h (P_mean < 0.0042; P_max < 0.0194).

Conclusion

The observed changes indicate that lotilaner may disrupt tick attachment. In ticks that attached, a progressive impairment of neuromuscular processes began within 2 h. Those irreversible changes could substantially reduce the risk of pathogen transmission from tick to host.

Anesthetic management of a pregnant broodmare with gastrointestinal colic

Gastrointestinal colic in mares during early pregnancy may require general anesthesia for surgical correction. There is a scarcity of literature identifying anesthetic risk factors associated with negative outcome in the pregnant mare. In this case report, a seven-year-old Thoroughbred broodmare, presenting for the investigation and treatment of colic in the fifth month of pregnancy, underwent surgery for the correction of right dorsal displacement of the large colon. Intraoperatively, interventions for maternal hypoxemia and hypotension were necessary. The mare recovered well from general anesthesia and was discharged from the hospital eleven days postoperatively. In this case report, the successful anesthetic management of a pregnant broodmare is described, and all aspects that may improve the outcome for both mare and fetus are considered, with emphasis on the prevention of cardiovascular and respiratory disturbances.

Knockout of the circadian gene, Per2, disrupts corticosterone secretion and results in depressive-like behaviors and deficits in startle responses

Background

The Period Circadian Regulator 2 (Per2) gene is important for the modulation of circadian rhythms that influence biological processes. Circadian control of the hypothalamus-pituitary-adrenal (HPA) axis is critical for regulation of hormones involved in the stress response. Dysregulation of the HPA axis is associated with neuropsychiatric disorders. Therefore, it is important to understand how disruption of the circadian rhythm alters the HPA axis. One way to address this question is to delete a gene involved in regulating a central circadian gene such as Per2 in an animal model and to determine how this deletion may affect the HPA axis and behaviors that are altered when the HPA axis is dysregulated. To study this, corticosterone (CORT) levels were measured through the transition from light (inactive phase) to dark (active phase). Additionally, CORT levels as well as pituitary and adrenal mRNA expression were measured following a mild restraint stress. Mice were tested for depressive-like behaviors (forced swim test (FST)), acoustic startle response (ASR), and pre-pulse inhibition (PPI).

Results

The present results showed that Per2 knockout impacted CORT levels, mRNA expression, depressive-like behaviors, ASR and PPI. Unlike wild-type (WT) mice, Per2 knockout (Per2) mice showed no diurnal rise in CORT levels at the onset of the dark cycle. Per2−/− mice had enhanced CORT levels and adrenal melanocortin receptor 2 (Mc2R) mRNA expression following restraint. There were no changes in expression of any other pituitary or adrenal gene. In the FST, Per2−/− mice spent more time floating (less time struggling) than WT mice, suggesting increased depressive-like behaviors. Per2−/− mice had deficits in ASR and PPI startle responses compared to WT mice.

Conclusions

In summary, these findings showed that disruption of the circadian system via Per2 gene deletion dysregulated the HPA stress axis and is subsequently correlated with increased depressive-like behaviors and deficits in startle response.

Balance Right in Multiple Sclerosis (BRiMS): a feasibility randomised controlled trial of a falls prevention programme

Background

Balance, mobility impairments and falls are problematic for people with multiple sclerosis (MS). The “Balance Right in MS (BRiMS)” intervention, a 13-week home and group-based exercise and education programme, aims to improve balance and minimise falls. This study aimed to evaluate the feasibility of undertaking a multi-centre randomised controlled trial and to collect the necessary data to design a definitive trial.

Methods

This randomised controlled feasibility study recruited from four United Kingdom NHS clinical neurology services. Patients ≥ 18 years with secondary progressive MS (Expanded Disability Status Scale 4 to 7) reporting more than two falls in the preceding 6 months were recruited. Participants were block-randomised to either a manualised 13-week education and exercise programme (BRiMS) plus usual care, or usual care alone.

Feasibility assessment evaluated recruitment and retention rates, adherence to group assignment and data completeness. Proposed outcomes for the definitive trial (including impact of MS, mobility, quality of life and falls) and economic data were collected at baseline, 13 and 27 weeks, and participants completed daily paper falls diaries.

Results

Fifty-six participants (mean age 59.7 years, 66% female, median EDSS 6.0) were recruited in 5 months; 30 randomised to the intervention group. Ten (18%) participants withdrew, 7 from the intervention group. Two additional participants were lost to follow up at the final assessment point. Completion rates were > 98% for all outcomes apart from the falls diary (return rate 62%).

After adjusting for baseline score, mean intervention—usual care between-group differences for the potential primary outcomes at week 27 were MS Walking Scale-12v2: − 7.7 (95% confidence interval [CI] − 17.2 to 1.8) and MS Impact Scale-29v2: physical 0.6 (CI − 7.8 to 9), psychological − 0.4 (CI − 9.9 to 9). In total, 715 falls were reported, rate ratio (intervention:usual care) for falls 0.81 (0.41 to 2.26) and injurious falls 0.44 (0.41 to 2.23).

Conclusions

Procedures were practical, and retention, programme engagement and outcome completion rates satisfied a priori progression criteria. Challenges were experienced in completion and return of daily falls diaries. Refinement of methods for reporting falls is therefore required, but we consider a full trial to be feasible.

Trial registration

ISRCTN13587999

Date of registration: 29 September 2016

Ex vivo synergistic effects of apixaban with dual anti-platelet therapy (DAPT) in lowering platelet reactivity and thrombin generation (SEARCH)

 

Direct oral anticoagulants such as apixaban are increasingly being evaluated clinically for the secondary prevention of cardiovascular events; however, their effects on platelet function in combination with dual anti-platelet therapy (DAPT) have not been fully investigated. The purpose of this translational, in vitro study was to determine if apixaban via inhibition of thrombin generation exhibits synergistic activity with DAPT to reduce platelet reactivity. Consented subjects with a prior history (&lt;12 mo) of ACS on DAPT regime with aspirin and clopidogrel (n=15; DAPT-C) or aspirin and ticagrelor (n=15; DAPT-T) were recruited, along with the age-matched healthy subjects as controls. Enrolled DAPT subjects had taken their prescribed regimen &gt;7 days prior to blood collection. Platelet-rich plasma from TSC anticoagulated blood was prepared and treated in vitro with nothing, a carrier control or apixaban (40, 90 and 220 ng/mL). The range of 40 to 220 ng/mL brackets the expected apixaban exposure at steady state with all three approved regimens with the 40 ng/mL treatment corresponding to &lt;5th percentile for the 2.5 mg bid dose, the 90 ng/mL corresponding to Cmax after the 2.5 mg bid or to Cmin after the 5 mg bid dose, and the 220 ng/mL corresponding to the Cmax after 10 mg bid dose. Platelet aggregation was measured by light transmission aggregometry (LTA) with tissue factor (TF) as agonist. Platelet p-selectin expression was measured by flow cytometry and thrombin generation was quantified. TF agonist was chosen to evaluate endogenous thrombin effects via Factor Xa activation (fXa). The CaCl2 concentration in the TF was titrated in the presence of peptide GPRP which minimized fibrin generation. The baseline maximal aggregation (MA) response was similar for both DAPT-T and DAPT-C (64%). Compared to DAPT alone, 90 and 220 ng/mL apixaban treatments decreased MA from 64% to 36% and 17% in the DAPT-T group and from 64% to 28% and 9% in the DAPT-C group (p&lt;0.009), respectively. Platelet P-selectin expression decreased by 53% in the DAPT-T group with 220 ng/mL apixaban treatment (p&lt;0.02) and in the DAPT-C group by 70% and 76% with 90 and 220 ng/mL apixaban treatment (p&lt;0.004), respectively, compared to DAPT alone. Apixaban treatment (90 and 220 ng/mL) significantly increased thrombin generation lag time and time-to-peak results and significantly decreased peak thrombin in both DAPT groups (p&lt;0.05). ACS patients on a DAPT regimen were susceptible to thrombin-mediated platelet activation via fXa. Apixaban treatment in vitro caused a larger reduction in thrombin-mediated platelet activation in the clopidogrel group compared to the ticagrelor group, consistent with ticagrelor having a more potent anti-platelet effect compared to clopidogrel. The in vitro addition of apixaban that corresponded to currently approved dosing regimens and at plasma drug levels routinely achieved demonstrated synergy with DAPT to reduce platelet reactivity and thrombin generation.

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Bristol-Myers Squibb

De novo design of picomolar SARS-CoV-2 miniprotein inhibitors

Targeting the interaction between the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spike protein and the human angiotensin-converting enzyme 2 (ACE2) receptor is a promising therapeutic strategy. We designed inhibitors using two de novo design approaches. Computer-generated scaffolds were either built around an ACE2 helix that interacts with the spike receptor binding domain (RBD) or docked against the RBD to identify new binding modes, and their amino acid sequences were designed to optimize target binding, folding, and stability. Ten designs bound the RBD, with affinities ranging from 100 picomolar to 10 nanomolar, and blocked SARS-CoV-2 infection of Vero E6 cells with median inhibitory concentration (IC50) values between 24 picomolar and 35 nanomolar. The most potent, with new binding modes, are 56- and 64-residue proteins (IC50 ~ 0.16 nanograms per milliliter). Cryo-electron microscopy structures of these minibinders in complex with the SARS-CoV-2 spike ectodomain trimer with all three RBDs bound are nearly identical to the computational models. These hyperstable minibinders provide starting points for SARS-CoV-2 therapeutics.

"How to" operate a pediatric neuropsychology practice during the COVID-19 pandemic: Real tips from one practice's experience

This paper aims to provide pediatric neuropsychologists with suggested processes and procedures to continue to provide neuropsychology services during the COVID-19 global pandemic. Our practice is located within an academic medical center/children's hospital, and setting-specific recommendations may not extend to all practices, though our hope is that others find guidance from our approach to providing pediatric neuropsychology evaluations when physical distancing is required. With consideration of ethics, equity, and assessment validity, we provide suggestions for a) modifying practices around seeing patients during COVID-19, b) tele-health for the pediatric neuropsychologist, c) safety standards and requirements, and d) working with special populations (e.g., Autism Spectrum Disorder, bilingual populations, immunocompromised patients, and acute inpatient assessment).

De novo design of picomolar SARS-CoV-2 miniprotein inhibitors

We used two approaches to design proteins with shape and chemical complementarity to the receptor binding domain (RBD) of SARS-CoV-2 Spike protein near the binding site for the human ACE2 receptor. Scaffolds were built around an ACE2 helix that interacts with the RBD, or de novo designed scaffolds were docked against the RBD to identify new binding modes. In both cases, designed sequences were optimized first in silico and then experimentally for target binding, folding and stability. Nine designs bound the RBD with affinities ranging from 100pM to 10nM, and blocked bona fide SARS-CoV-2 infection of Vero E6 cells with IC ₅₀ values ranging from 35 pM to 35 nM; the most potent of these - 56 and 64 residue hyperstable proteins made using the second approach - are roughly six times more potent on a per mass basis (IC ₅₀ ~ 0.23 ng/ml) than the best monoclonal antibodies reported thus far. Cryo-electron microscopy structures of the SARS-CoV-2 spike ectodomain trimer in complex with the two most potent minibinders show that the structures of the designs and their binding interactions with the RBD are nearly identical to the computational models, and that all three RBDs in a single Spike protein can be engaged simultaneously. These hyperstable minibinders provide promising starting points for new SARS-CoV-2 therapeutics, and illustrate the power of computational protein design for rapidly generating potential therapeutic candidates against pandemic threats.

Buprenorphine-naloxone use in pregnancy: a systematic review and metaanalysis

OBJECTIVE

The goal of this systematic review and metaanalysis is to compare pregnancy outcomes between pregnant women undergoing treatment for opioid use disorder with buprenorphine-naloxone and those undergoing treatment for opioid use disorder with other forms of medication-assisted treatment.

STUDY DESIGN

PubMed, Embase, PsycINFO, Cochrane Clinical Trials, and Web of Science were searched to identify studies assessing the relationship between maternal buprenorphine-naloxone use and pregnancy outcomes. Outcomes assessed included neonatal abstinence syndrome diagnosis and treatment, neonatal intensive care unit admission, length of neonatal hospital stay, delivery complications, mode of delivery, labor analgesia, illicit drug use, medication-assisted treatment dosage, gestational age at delivery, breastfeeding status, miscarriage, congenital anomalies, intrauterine fetal demise, birthweight, head circumference, length, and Apgar scores.

RESULTS

Overall, 5 studies comprising 6 study groups met the inclusion criteria. Of the 1875 mother-baby dyads available for analysis, medications prescribed as part of the medication-assisted treatment included buprenorphine-naloxone, buprenorphine alone, methadone, or long-acting opioids. There were no serious adverse maternal or neonatal outcomes associated with maternal buprenorphine-naloxone use reported among any of the studies. Women prescribed with buprenorphine-naloxone for delivered neonates who were less likely to require treatment for neonatal abstinence syndrome were compared with pregnant women prescribed with other opioid agonist medications. Of the remaining outcomes assessed, metaanalysis did not detect any statistically significant differences when comparing the groups of women using buprenorphine-naloxone with the groups of women prescribed with other medications as part of the medication-assisted treatment.

CONCLUSION

Pregnant women undergoing treatment for opioid use disorder with buprenorphine-naloxone do not experience significantly different pregnancy outcomes than women undergoing treatment with other forms of opioid agonist medication-assisted therapy.

High Recreational Gamblers Show Increased Stimulatory Effects of an Acute Laboratory Gambling Challenge

Gambling in moderation is a socially acceptable behavior and over 60% of the Swedish population gambles every year. It has been seen that slot machines are one of the most addictive and problematic forms of gambling and contribute highly to an addictive behavior. It is unclear why some individuals intensify their gambling behavior over time to extreme levels while others do not. Initial positive response of a drug or as in this case a gambling behavior, most likely influences the likelihood of continuing use in non-addicted individuals. Therefore, we wanted to investigate if recreational gamblers show an altered subjective response to an online gambling challenge, e.g. to casino gambling. The present study was designed to examine the subjective effects after an acute gambling challenge, in healthy recreational gamblers compared with non-gamblers. Eighty-two subjects participated in the study. They were challenged with an acute online slot machine gambling challenge and self-report questionnaires of mood and blood pressure were taken before and after gambling. The gamblers, and more specifically the high recreational gamblers, reported increased stimulative effects after the gambling challenge in comparison to the non-gamblers. Findings suggests that gamblers experience significantly higher arousal effects to an acute online slot machine challenge. This response may be a uniquely predictive behavior for increased risk of gambling addiction.

Diderot Reconsidered: Visual Impairment and Auditory Compensation

Two general models for auditory compensation attending visual loss, structural and strategic, are discussed in the light of available research. It is suggested that previous dismissals of structural forms of auditory compensation may be in error, at least for those who are more profoundly and congenitally impaired.

Maternal Factors Related to Infant Motor Development at 4 Months of Age

Background: Exercise during pregnancy and breastfeeding after pregnancy both positively influence a number of infant outcomes. However, whether physical activity during late pregnancy and breastfeeding postpartum influence motor development in the offspring at 4 months of age is unknown. Research Aim: The purposes of this study were to investigate the relationships between several important modifiable factors (i.e., maternal physical activity during late pregnancy and breastfeeding after pregnancy) on infant motor development at 4 months of age. Materials and Methods: Thirty-three women-infant pairs participated in this prospective longitudinal study. Maternal physical activity was assessed during late pregnancy with wrist-worn accelerometers for 7 consecutive days. Surveys were provided to determine infant feeding practices and other variables that could influence infant motor development. A pediatric board-certified physical therapist assessed infant motor development at 4 months using the Alberta Infant Motor Scale. Results: Infants who were exclusively breastfed had the highest motor development percentiles when compared with those whose mothers were supplementing with or using formula exclusively (exclusive breastfeeding: 64.3 ± 20.1, combination of mother's own milk and formula: 43.5 ± 5.0, exclusive formula: 31.5 ± 15.1, p = 0.001). No associations between physical activity levels during late pregnancy and infant motor development percentiles at 4 months were found (sedentary time: r = -0.057, p = 0.75; light activity: r = -0.074, p = 0.68; moderate activity: r = -0.094, p = 0.60). Conclusions: Infants who were exclusively breastfed had higher motor development percentiles at 4 months of age than those infants whose mothers supplemented with or used formula exclusively. Physical activity levels during late pregnancy were not related to infant motor development percentiles, which suggests that physical activities do not appear to be harmful to infant motor development.

Visual Immunoprecipitate Assay (VIP) for Listeria monocytogenes and Related Listeria Species Detection in Selected Foods: Collaborative Study

Six foods representing a variety of food products were analyzed by the Assurance Listeria polyclonal enzyme immunoassay (EIA) and by either the Bacteriological Analytical Manual or the U.S. Department of Agriculture culture method for detecting Listeria monocytogenes and related Listeria species. Samples of each food type, at each inoculation level, were analyzed simultaneously by both methods. A total of 19 laboratories representing federal government agencies and private industry in the United States and Canada participated. Food types were inoculated with Listeria species including L. monocytogenes, with the exception of 3 lots of green beans, which were naturally contaminated. During this study, 1764 samples and controls were analyzed and confirmed, of which 492 were positive and 947 were negative by both methods. There were 159 samples that were positive by culture method but negative by the EIA and 188 that were negative by culture method but positive by EIA. Twenty-two samples were negative by EIA and by culture method but confirmed positive when Assurance selective enrichment broths were subcultured to selective agar. The Assurance polyclonal EIA for detecting L. monocytogenes and related Listeria species in foods has been adopted first action by AOAC INTERNATIONAL.

Assurance Enzyme Immunoassay for Detection of Enterohemorrhagic Escherichia coli 0157:H7 in Selected Foods: Collaborative Study

Five foods types were analyzed by the Assurance EHEC (Escherichia coli 0157:H7) enzyme immunoassay (EIA) and by the Bacteriological Analytical Manual (BAM) culture method. Each sample of each food type at each inoculation level was simultaneously analyzed by both methods. A total of 21 laboratories representing state and federal government agencies and private industry in the United States and Canada participated. Samples were inoculated with E. coli 0157:H7, except for one lot of poultry that was naturally contaminated. A total of 1304 samples and controls were analyzed and confirmed, of which 473 were positive and 818 were negative by both methods. Thirteen samples were positive by BAM but negative by EIA. Because of the study design, it was not possible for the BAM method to produce false-negative or falsepositive results. The Assurance method for detection of E. coli OI57:H7 in selected foods has been adopted first action by AOAC INTERNATIONAL.

Visual Immunoprecipitate Assay (VIP) for Detection of Enterohemorrhagic Escherichia coli (EHEC) 0157:H7 in Selected Foods: Collaborative Study

Five foods representative of a variety of food products were analyzed by the Visual Immunoprecipitate Assay (VIP) and the Bacteriological Analytical Manual (BAM) culture method for the presence of Escherichia coli 0157: H7. A total of 21 laboratories representing state and federal government agencies, as well as private industry, in the United States and Canada participated. Food types were inoculated with strains of E. coli 0157:H7, with the exception of one lot of poultry, which was naturally contaminated. During this study, a total of 1377 samples and controls were analyzed and confirmed, of which 508 were positive and 867 were negative by both methods. Two samples were positive by BAM and negative by VIP. Because of the study design, it was not possible for the BAM method to produce false-negative or false-positive results. The VIP assay for detection of EHEC in selected foods has been adopted first action by AOAC INTERNATIONAL.