Impact of varying wave periods of COVID‐19 on in‐hospital mortality and length of stay for admission through emergency department: A territory‐wide observational cohort study

BackgroundThe COVID‐19 pandemic has been associated with excess mortality and reduced emergency department attendance. However, the effect of varying wave periods of COVID‐19 on in‐hospital mortality and length of stay (LOS) for non‐COVID disease for non‐COVID diseases remains unexplored.MethodsWe examined a territory‐wide observational cohort of 563,680 emergency admissions between January 1 and November 30, 2020, and 709,583 emergency admissions during the same 2019 period in Hong Kong, China. Differences in 28‐day in‐hospital mortality risk and LOS due to COVID‐19 were evaluated.ResultsThe cumulative incidence of 28‐day in‐hospital mortality increased overall from 2.9% in 2019 to 3.6% in 2020 (adjusted hazard ratio [aHR] = 1.22, 95% CI 1.20 to 1.25). The aHR was higher among patients with lower respiratory tract infection (aHR: 1.30 95% CI 1.26 to 1.34), airway disease (aHR: 1.35 95% CI 1.22 to 1.49), and mental disorders (aHR: 1.26 95% CI 1.15 to 1.37). Mortality risk in the first‐ and third‐wave periods was significantly greater than that in the inter‐wave period (p‐interaction < 0.001). The overall average LOS in the pandemic year was significantly shorter than that in 2019 (Mean difference = −0.40 days; 95% CI −0.43 to −0.36). Patients with mental disorders and cerebrovascular disease in 2020 had a 3.91‐day and 2.78‐day shorter LOS than those in 2019, respectively.ConclusionsIncreased risk of in‐hospital deaths was observed overall and by all major subgroups of disease during the pandemic period. Together with significantly reduced LOS for patients with mental disorders and cerebrovascular disease, this study shows the spillover effect of the COVID‐19 pandemic.     

Isolation,Characterization, and Genome Analysis of a Novel Bacteriophage,Escherichia Phage vB_EcoM-4HA13, Representing a New Phage Genus in the Novel Phage Family Chaseviridae

Shiga toxin-producing Escherichia coli (STEC) is one of the leading causes of foodborne illnesses in North America and can lead to severe symptoms, with increased fatality risk for young children. While E. coli O157:H7 remains the dominant STEC serotype associated with foodborne outbreaks, there has been an increasing number of non-O157 STEC outbreaks in recent years. For the food industry, lytic bacteriophages offer an organic, self-limiting alternative to pathogen reduction—one that could replace or reduce the use of chemical and physical food processing methods. From EHEC-enriched sewage, we isolated a novel bacteriophage, vB_EcoM-4HA13 (4HA13). Phenotypic characterizations revealed 4HA13 to possess a myoviral morphotype, with a high specificity to non-motile O111 serotype, and a long latent period (90 min). Through genomic analyses, this 52,401-bp dsDNA phage was found to contain 81 CDS, but no detectable presence of antibiotic resistance, integrase, or virulence genes. A BLASTn search for each of the identified 81 CDS yielded homologues with low levels of similarity. Comparison of RNA polymerase and terminase large subunit amino acid sequences led to the proposal and acceptance of a new bacteriophage family, Chaseviridae, with 4HA13 representing a new species and genus. The discovery of this phage has broadened our current knowledge of bacteriophage diversity.     

Nuclear factor-kappaB translocation mediates double-stranded ribonucleic acid-induced NIT-1 beta-cell apoptosis and up-regulates caspase-12 and tumor necrosis factor receptor-associated ligand (TRAIL)

The mechanism of induction of apoptosis by double-stranded RNA (dsRNA) is not fully characterized. The dsRNA is normally present in extremely low quantities in cells, but following infection with RNA viruses, large quantities of the dsRNA viral replicative intermediate may be produced triggering the antiviral response as well as cell death. In this report, transfection of polyinosinic-polycytidylic acid [poly(I:C)] into NIT 1 cells has been used as a model of intracellular dsRNA-induced beta-cell apoptosis. At 18 h post transfection, 45% of the cells were apoptotic as indicated by terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick end-labeling (TUNEL) staining, and this was accompanied by an increase in nuclear factor kappaB (NF-kappaB) p50/p65 nuclear translocation and cleavage of caspases 3 and 8. The NF-kappaB inhibitor peptide, SN50, significantly reduced caspase-3 activity and the percentage of TUNEL-positive cells, substantiating a role for NF-kappaB in inducing intracellular dsRNA-mediated apoptosis. Concomitantly, RNA-dependent protein kinase activity was observed at 3 h post transfection along with phosphorylation and degradation of inhibitory kappaB-alpha. Expression of TRAIL (TNF-related apoptosis-inducing ligand), Fas, IL-15, and caspase-12 mRNAs was up-regulated in the presence of poly(I:C) but not when SN50 was also added. In contrast, there was no change detected in Fas, Fas-associated death domain, Bcl-2, Bcl-xl, Bax, p53, or XIAP(X-linked inhibitor of apoptosis protein) expression up to 12 h after poly(I:C) transfection. In addition, caspase-12 was cleaved, and phosphorylation of eukaryotic initiation factor 2alpha occurred, suggesting that an endoplasmic reticulum stress pathway was involved in addition to NF-kappaB induction of an extrinsic pathway, possibly mediated by TNF-related apoptosis-inducing ligand.     

Program Directors' Views of the Effect of Managed Care on Substance Abuse Programs in Southern California

This article reports the results of semi-structured interviews with substance abuse treatment (SAT) program directors (PDs) regarding the ways SAT is being influenced by managed care (MC), plans for future SAT, and strategies for decreasing costs of care. It compares findings to an earlier survey of 50 SAT PDs.

Interviews were conducted in 20 SAT programs to gather information about treatment delivery since the advent of MC, including PD responsibilities, funding source, treatment intensity, location, duration, and methods of treatment. Open-ended responses were used to gather information about current and future plans in providing SAT, and awareness of new types of treatment being planned by organizations impacted by MC.

PDs reported changes in SAT secondary to MC such as decreased treatment length, limiting of inpatient and outpatient services, and delayed treatment secondary to benefit determination. Political and economic constraints were seen as barriers to providing adequate and effective services. SAT being subsumed by mental health was viewed as problematic along with an emerging split between alcohol abuse and drug treatment. A positive emerging treatment trend was the development of targeted programs for special need groups.

PDs revealed a variety of strategies that have promoted necessary adaptations to economic and political influences within the structure of managed behavioral care. Strategies such as varying treatment length, modality, and subspecialty care reflected necessary adaptations to diverse market needs.

Managed care continues to have a tremendous impact on the delivery of SAT services. While MC has helped to contain costs, negative outcomes are decreased availability of appropriate care and overtaxing of units that have survived MC cut backs. However, special need programs have allowed SAT programs to specialize, expand, and even flourish in today's competitive SAT market. Interviews with PDs reinforced the need for maintaining quality and diversified SAT services in today's MC environment.     

The importance of recognizing postural pseudoanemia

The determination of the packed red cell volume and the hemoglobin level has been paramount for monitoring anemia and blood loss for patients in the hospital setting. Recently, these variables have been studied during various control conditions including changes in posture. It has been found that the hematocrit changes markedly with alteration of body posture, in such a way that shifts of estimated blood volume of 1 pint can commonly be elicited by a simple change of posture from supine to upright or vice versa. Therefore, it is important to recognize that in addition to the numerous pathological conditions that may affect the value of the packed cell volume, certain physiological maneuvers may have an equal impact and may confound the accurate assessment of true pathological changes in these variables. Thus, changes in posture can lead to substantial changes in hematocrit, which may be attributed mistakenly to blood loss or acute anemia and may result in a cascade of unnecessary diagnostic costs. In reality, these changes represent postural pseudoanemia, a normal physiological response to a change in position from standing to lying. This stydy was supported in part by grants from the National Institutes of Health (RR00095, 2PO1 HL55693). The Daxor Corporation provided the Volumex iodine 131-labeled human serum albumin used for plasma volume determination at no cost to the authors. Dr. Jacob was a Merck International Fellow. Dr. Raj is supported by a K23 award from the National Institutes of Health (K23 RR020783-01A1). This work has been previously reported in ref. 1.     

The prevalence, intensities and risk factors associated with geohelminth infection in tea-growing communities of Assam, India

OBJECTIVE: To determine the prevalence, intensity and associated risk factors for infection with Ascaris, hookworms and Trichuris in three tea-growing communities in Assam, India. METHODS: Single faecal samples were collected from 328 individuals and subjected to centrifugal flotation and the Kato Katz quantitation technique and prevalence and intensities of infection with each parasite calculated. Associations between parasite prevalence, intensity and host and environmental factors were then made using both univariate and multivariate analysis. RESULTS: The overall prevalence of Ascaris was 38% [95% confidence interval (CI): 33, 43], and the individual prevalence of hookworm and Trichuris was 43% (95% CI: 38, 49). The strongest predictors for the intensity of one or more geohelminths using multiple regression (P < or = 0.10) were socioeconomic status, age, household crowding, level of education, religion, use of footwear when outdoors, defecation practices, pig ownership and water source. CONCLUSION: A universal blanket treatment with broad-spectrum anthelmintics together with promotion of scholastic and health education and improvements in sanitation is recommended for helminth control in the communities under study.     

Augmented Binary Substitution: Single-pass CDR germ-lining and stabilization of therapeutic antibodies

Although humanized antibodies have been highly successful in the clinic, all current humanization techniques have potential limitations, such as: reliance on rodent hosts, immunogenicity due to high non-germ-line amino acid content, v-domain destabilization, expression and formulation issues. This study presents a technology that generates stable, soluble, ultrahumanized antibodies via single-step complementarity-determining region (CDR) germ-lining. For three antibodies from three separate key immune host species, binary substitution CDR cassettes were inserted into preferred human frameworks to form libraries in which only the parental or human germ-line destination residue was encoded at each position. The CDR-H3 in each case was also augmented with 1 ± 1 random substitution per clone. Each library was then screened for clones with restored antigen binding capacity. Lead ultrahumanized clones demonstrated high stability, with affinity and specificity equivalent to, or better than, the parental IgG. Critically, this was mainly achieved on germ-line frameworks by simultaneously subtracting up to 19 redundant non-germ-line residues in the CDRs. This process significantly lowered non-germ-line sequence content, minimized immunogenicity risk in the final molecules and provided a heat map for the essential non-germ-line CDR residue content of each antibody. The ABS technology therefore fully optimizes the clinical potential of antibodies from rodents and alternative immune hosts, rendering them indistinguishable from fully human in a simple, single-pass process.Monoclonal antibodies are a highly established technology in drug development and the majority of currently approved therapeutic antibodies are derived from immunized rodents (1). The advent of display libraries and engineered animals that can produce “fully human” antibody v-gene sequences has had a significant positive impact on antibody drug discovery success (1), but these technologies are mostly the domain of biopharmaceutical companies. Antibodies from wild-type animals that are already extant, or can be freely developed, will therefore continue to be a rich source of therapeutic candidates. In addition, phylogenetically distant hosts such as rabbits and chickens may become a valuable source of monoclonals with clinical potential against challenging targets (2, 3).Chimerization of murine antibodies can reduce anti-IgG responses in man (4), but murine v-domains may still have provocative T-cell epitope content, necessitating “humanization” of their framework regions (5, 6). Classical humanization “grafts” murine CDRs into human v-gene sequences (7), but this typically leads to significant reduction in affinity for target, so murine residues are introduced at key positions in the frameworks (a.k.a. “back-mutations”), to restore function (8). Importantly, humanized antibodies do elicit lower immunogenicity rates in patients in comparison with chimerics (9).Alternative humanization methods have also been developed based on rational design or empirical selection (10–17), but current methods still all suffer from flaws, such as: high non-germ-line amino acid content retention (5, 6); grafting into poorly understood frameworks (13); resource-intensive, iterative methods (15, 18); requirement for homology modeling of the v-domains, which is often inaccurate (19, 20), or a cocrystal structure with the target antigen (14). Methods that allow humanization into preferred frameworks can add numerous framework mutations (18, 21), which may destabilize the v-domains (22), encode new T-cell epitopes, or introduce random amino acid mutations in CDRs (12, 13) that can drive polyspecificity and/or poor PK properties (23).Critically, testing of protein therapeutics in monkeys has been shown to be nonpredictive of immune responses in man (24) and animal immunogenicity testing has been suggested to be of little value in biosimilar development (25). Current evidence suggests that the main risk factors for antibody immunogenicity in man are human T-cell epitope content and, to a lesser extent, T-cell independent B-cell responses (6). B-cell epitopes are challenging to predict and B-cell-only responses to biotherapeutics appear to be driven by protein aggregates (26). The key attributes to reduce antibody immunogenicity risk in the clinic appear to be: low T-cell epitope content, minimized non-germ-line amino acid content and low aggregation potential (27).In recent years, several reports have strongly suggested that CDRs might be malleable in ways that could not be predicted a priori. Random mutagenesis and reselection of a classically humanized rat antibody found that individual framework back mutations and CDR residues could revert to human germ-line sequence, while maintaining or even improving the function of the antibody (28). A number of humanization studies have now also shown that a small number of positions in the CDRs could be substituted for human germ-line residues, through a rational design cycle of reversion mutations (5, 29). In addition to these observations, a number of structural analyses have illustrated the common redundancy of sequence space in antibody binding interfaces. Despite typically large buried interfaces between antibodies and protein targets, only a subset of residues in the CDRs of antibodies usually makes contact with antigen (30–32). Alanine scanning of CDR loops has also shown that only a limited number of residues directly affect antigen binding affinity (33). Indeed, it has even been shown that redundant paratope space in a single antibody may be exploited to engineer binding specificity to two separate targets (34). Additionally, CDR loop structures are known to be restricted to a limited number of canonical classes, despite amino acid variation within those classes at specific positions (35–38). These observations led us to hypothesize that, under the right experimental conditions, a large proportion of residues in grafted animal CDRs could be concurrently replaced by the residues found at the corresponding positions in a given destination human germ-line v-gene.In this study, we generated combinatorial libraries on the basis of a design principle we have named “Augmented Binary Substitution” (ABS). Each library was based on a single starting antibody: rat anti-RAGE (28), rabbit anti-A33 (2), and chicken anti-pTau (3). These libraries were built into human germ-line frameworks of high predicted stability and solubility, then interrogated via phage display and screened to identify lead clones with epitope specificity and affinity equivalent to the parental clone. ABS proved to be a facile, rapid method that retains only the functionally required CDR content of the parental animal antibody, without the need for prior crystal-structure insight. Notably, this CDR germ-lining approach generated highly stable and soluble human IgGs, from multiple key antibody discovery species, that have minimized predicted human T-cell epitope content. The reproducibility of these findings across three antibodies from three disparate species demonstrates a fundamental plasticity in antibody paratopes that can be broadly exploited in therapeutic antibody optimization.     

Laparoscopic-assisted versus open resection of right-sided colonic cancer—a prospective randomized controlled trial

Purposes  

This study aims to compare the perioperative outcomes and survival between laparoscopic-assisted right hemicolectomy (LARH) and open right hemicolectomy (ORH) for right-sided colon cancer.