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1.
Open Forum Infectious Diseases ; 9(Supplement 2):S449, 2022.
Article in English | EMBASE | ID: covidwho-2189718

ABSTRACT

Background. Predictors of SARS-CoV-2 RNA levels and changes over time during early COVID-19 are not well characterized. Methods. ACTIV-2 is a phase II/III randomized, placebo-controlled, platform trial to evaluate investigational agents for treatment of COVID-19 in non-hospitalized adults. Participants enrolled within 10 days of symptom onset. Nasopharyngeal samples were collected for SARS-CoV-2 RNA testing on Days 0, 3, 7, 14 and 28;RNA was quantified with qPCR assay. SARS-CoV-2 seropositivity was defined as detectable IgG to any of nucleocapsid, receptor binding domain, S1 and S2 antigens by Bio-Plex multiplex assay. Censored linear regression and repeated measures Poisson models evaluated predictors of RNA including age, sex, race, ethnicity, risk of severe COVID-19, diabetes, BMI, obesity (BMI > 35 kg/m2) and serostatus. Results. The study enrolled 537 participants from Aug 2020 to July 2021 at US sites. Median age was 48 years;49% were female sex, >99% cis-gender, 83% white, 29% Hispanic/Latino, and 21% had BMI > 35 kg/m2. At Day 0, median symptom duration was 6 days, 50% were seropositive (2 were vaccinated) and 17% had RNA below the lower limit of quantification (LLoQ). Higher Day 0 RNA was associated with shorter symptom duration (Spearman correlation = -0.40, p< 0.001), as well as older age, white race, lower BMI and seronegativity, even when adjusting for symptom duration (all p< 0.03). Among the 203 on placebo with Day 0 RNA >= LLoQ, female sex had larger decreases in RNA at Day 3 vs male sex (difference in mean change: -0.8 log10 copies/mL (95% CI: -1.2, -0.4), p< 0.001) when adjusted for symptom duration and Day 0 RNA;this difference was also observed when evaluating the proportion with RNA < LLoQ at Day 3 (Risk Ratio (95% CI): 2.38 (1.11, 5.09)). Seropositivity at Day 0 was associated with higher probability of RNA < LLoQ at Days 3 and 7 (p< 0.001) in adjusted models. Seropositivity at Day 0 did not differ by sex. Conclusion. In this well characterized clinical trial cohort, shorter symptom duration, older age, white race, lower BMI and seronegativity were associated with higher RNA in early infection. Female sex and seropositivity were associated with earlier viral clearance. Further research is needed to determine if viral decay differences mediated by these host factors influence clinical outcomes.

2.
Clinical Toxicology ; 60(Supplement 2):32, 2022.
Article in English | EMBASE | ID: covidwho-2062722

ABSTRACT

Background: Azathioprine is a purine analog metabolized to 6- mercaptopurine (6-MP) utilizing glutathione. Its high oral bioavailability and longer duration of action make it viable as a treatment for ulcerative colitis or as an anti-rejection medication for renal transplant patients. Specific experience in overdose with this agent is limited although toxicity mimics 6-MP including hepatotoxicity, delayed leukopenia, and acute interstitial nephritis. Case report: A 46 year old female (64 kg) with a history of ulcerative colitis, migraines, and anxiety presented with a selfreported intentional ingestion of 1000mg azathioprine and presented to care approximately 8 h post-ingestion. Her compliance with azathioprine preceding the ingestion was unclear. She reported taking her other medications as prescribed (tadalafil, sulfasalazine, fioricet, alprazolam) the day prior to presentation. Other than one episode of emesis without pill fragments, myalgias, headache she had no other symptoms. Her presenting vital signs were HR 84, RR 22, BP 90/63, T 36.2 degreeC. Initial labs included a normal chemistry profile, undetectable serum acetaminophen and salicylates, an ethanol level of 50 mg/dL and venous lactate of 1.6mmol/L. She received a total of 3 L of crystalloid IV fluids with improvement in blood pressure to 125/66 and was transferred for higher level of care. Due to the delay in presentation and well appearance, activated charcoal and hemodialysis were considered but deferred. While inpatient she had laboratory evaluation including CBC and differential every 8 h. In the ED she developed a fever, 38.1 degreeC. PCR testing for COVID-19 was negative. Whole blood thiopurine metabolites (Prometheus Biosciences, Test 3200) were sent approximately 33 h from time of ingestion. 6-thioguanine levels were 108 pmol/8x10degree8 RBC, below the therapeutic reference range (230-400 pmol/8x10degree8 RBC). 6-methylmercaptopurine metabolites were below the lower limit of quantification (761pmol/8x10degree8 RBC). Genetic testing for thiopurine S-methyltransferase was declined by the patient. She was hospitalized for 4 days and did not develop any substantial vital sign abnormalities or creatinine elevation. Her absolute neutrophil count dropped to 500/mm3 approximately 76 h post-ingestion, but started to improve 84 h post-ingestion and granulocyte-macrophage colony-stimulating factor was deferred. Her peak AST was 113 IU/L, approximately 46 h post-ingestion and returned to normal (16 IU/L) upon follow-up 7 days postingestion. White blood cell count 7 days post-ingestion was 4.3 K/mm3. Discussion(s): Azathioprine overdose is rarely reported in the literature. Case reports describe delayed leukopenia and hepatotoxicity from repeat supratherapeutic ingestions, however, based upon limited experience serious toxicity from single acute ingestions appears rare. A report of a single acute ingestion of 7500mg of azathioprine resulted in moderate leukopenia (4.1 K/ mm3) 3 days post-ingestion. Peak immunosuppressive effects can take up to 2 weeks from initiation or change in dose. Symptoms in this case are consistent with effects from azathioprine including vomiting, transient hypotension, and myalgias. Conclusion(s): Intentional ingestions of azathioprine are infrequently reported and can result in serious delayed myelosuppression. We report a case of a single acute ingestion of >15 mg/kg resulting in delayed myelosuppression managed conservatively.

3.
Resources, Conservation and Recycling Advances ; 14, 2022.
Article in English | EMBASE | ID: covidwho-1886052

ABSTRACT

Bauxite residue (BR), simultaneously an environmental challenge as well as known to be a secondary resource for resources various valuable metals like Ti, V, Ga, and rare earth metal (REM). Lack of understanding and technology detects BR to be stockpiled which is counterproductive considering the environment, land scarcity, and management of BR inventories. As BR remains unexploited, significant amounts of REMs in BR remain unlocked, which are critical metals from green energy, environmental sustainability, and supply chain bottleneck perspective. Our current investigation analyses the potential of BR as secondary resources and quantity and worth of REM being remains unlocked. The quantitative content of global bauxite, alumina, and BR production during the last 5 decades have been analyzed. Also, plausible BR generation in the next 3 decades has been estimated. Considering the content of REM in BR amount of REM either stockpiled or to be stockpiled along with BR has been analyzed. Our study indicated about 9.14 million tons of REM remain locked in the stockpiled BR, 31.24 million tons of REM remain locked in the bauxite reserve. The worth of worldwide REM oxide remains unexploited in bauxite reserves and locked in stockpiled BR could be approximately $5000 billion, potentially can meet current and project demand of REM abundantly.

4.
J Mass Spectrom Adv Clin Lab ; 25: 27-35, 2022 Aug.
Article in English | MEDLINE | ID: covidwho-1885932

ABSTRACT

Introduction: Remdesivir (GS-5734) is a nucleoside analog prodrug with antiviral activity against several single-stranded RNA viruses, including the novel severe respiratory distress syndrome virus 2 (SARS-CoV-2). It is currently the only FDA-approved antiviral agent for the treatment of individuals with COVID-19 caused by SARS-CoV-2. However, remdesivir pharmacokinetics/pharmacodynamics (PK/PD) and toxicity data in humans are extremely limited. It is imperative that precise analytical methods for the quantification of remdesivir and its active metabolite, GS-441524, are developed for use in further studies. We report, herein, the first validated anti-viral paper spray-mass spectrometry (PS-MS/MS) assay for the quantification of remdesivir and GS-441524 in human plasma. We seek to highlight the utility of PS-MS/MS technology and automation advancements for its potential future use in clinical research and the clinical laboratory setting. Methods: Calibration curves for remdesivir and GS-441524 were created utilizing seven plasma-based calibrants of varying concentrations and two isotopic internal standards of set concentrations. Four plasma-based quality controls were prepared in a similar fashion to the calibrants and utilized for validation. No sample preparation was needed. Briefly, plasma samples were spotted on a paper substrate contained within pre-manufactured plastic cassette plates, and the spots were dried for 1 h. The samples were then analyzed directly for 1.2 min utilizing PS-MS/MS. All experiments were performed on a Thermo Scientific Altis triple quadrupole mass spectrometer utilizing automated technology. Results: The calibration ranges were 20 - 5000 and 100 - 25000 ng/mL for remdesivir and GS-441524, respectively. The calibration curves for the two antiviral agents showed excellent linearity (average R2 = 0.99-1.00). The inter- and intra-day precision (%CV) across validation runs at four QC levels for both analytes was less than 11.2% and accuracy (%bias) was within ± 15%. Plasma calibrant stability was assessed and degradation for the 4 °C and room temperature samples were seen beginning at Day 7. The plasma calibrants were stable at -20 °C. No interference, matrix effects, or carryover was discovered during the validation process. Conclusions: PS-MS/MS represents a useful methodology for rapidly quantifying remdesivir and GS-441524, which may be useful for clinical PK/PD, therapeutic drug monitoring (TDM), and toxicity assessment, particularly during the current COVID-19 pandemic and future viral outbreaks.

5.
Topics in Antiviral Medicine ; 30(1 SUPPL):173, 2022.
Article in English | EMBASE | ID: covidwho-1880928

ABSTRACT

Background: The discovery and development of SARS-CoV-2 therapies remains a priority. SAB-185 is a Transchromosomic, bovine-derived, fully human polyclonal immunoglobulin product for SARS-CoV-2 being studied in ACTIV-2, randomized controlled platform trial evaluating the safety and efficacy of investigational agents for non-hospitalized adults with mild-moderate COVID-19 Methods: This Phase II trial was a superiority comparison of SAB-185 vs. placebo. Participants with confirmed SAR-CoV-2 infection received intravenous infusion of SAB-185 (3,840 Units/kg) or placebo. Primary outcome measures were proportion of participants with SARS-CoV-2 RNA < lower limit of quantification (LLoQ) in nasopharyngeal (NP) swab, time to improvement in targeted symptoms for 2 consecutive days after Day 0, and safety through Day 28. Secondary outcomes included quantitative NP RNA levels and all-cause hospitalizations and deaths. Antiviral or clinical efficacy and safety criteria for graduation to Phase III were pre-specified. Results: From April to August 2021, randomized participants from 42 sites in the US received SAB-185 (N=107) or placebo (N=106). Median age was 38 years (quartiles: 30,48), 54% female, >98% cis-gender, 7% Black/African-American, 50% Hispanic, and 11% were classified as high-risk for COVID-19 progression, with median 4 days (3,6) from symptom onset. Day 0 NP SARS-CoV-2 RNA levels were similar between SAB-185 and placebo: 4.80 vs 4.80 log10 copies/ml. No differences were observed in the proportion with NP SARS-CoV-2 RNA< lower limit of quantification (LLoQ) in nasopharyngeal (NP) swab, time to improvement in targeted symptoms for 2 consecutive days after Day 0, and safety through Day 28. Secondary outcomes included quantitative NP RNA levels and all-cause hospitalizations and deaths. Antiviral or clinical efficacy and safety criteria for graduation to phase 3 were pre-specified. Conclusion: SAB-185 was safe in this Phase II study. While no significant differences to placebo were seen in symptom duration and proportion of participants with NP SARS-CoV-2 RNA< lower limit of quantification (LLoQ) in nasopharyngeal (NP) swab, time to improvement in targeted symptoms for 2 consecutive days after Day 0, and safety through Day 28. Secondary outcomes included quantitative NP RNA levels and all-cause hospitalizations and deaths. Antiviral or clinical efficacy and safety criteria for graduation to phase 3 were pre-specified.

6.
Topics in Antiviral Medicine ; 30(1 SUPPL):76, 2022.
Article in English | EMBASE | ID: covidwho-1880509

ABSTRACT

Background: SARS-CoV-2 viremia is associated with adverse outcomes in COVID-19. The immunologic mediators of this relationship remain under-explored. In this study, we aimed to evaluate the correlation between immune exhaustion markers, SARS-CoV-2 viremia clearance and clinical outcomes. Methods: We included 126 participants with confirmed SARS-CoV-2 infection who were hospitalized at an urban hospital in Boston, Massachusetts, during the first surge of the COVID-19 pandemic in early 2020. Plasma samples from days 0, 3, and 7 of hospitalization were available for analyses. The plasma SARS-CoV-2 viral load was determined by reverse transcription quantitative PCR (RT-qPCR). Proteomics data were generated using the Olink platform and neutralization level was assessed using a pseudovirus neutralization assay. Viremia persistence was defined as >40 copies/ml (detection limit) if the baseline detectable viremia was <1000 copies/ml, or >100 copies/ml (quantification limit) if the baseline viremia was ≥1000 copies/ml at day 7 of admission. Partial least-squares discriminant analysis (PLS-DA) was used to select exhaustion markers that could distinguish viremia persistence and clearance. An exhaustion score was generated based on features selected by PLS-DA and was divided into four quartiles. Differentially expressed proteins between 1st and 4th quartiles were determined by linear model adjusting for baseline characteristics. R (4.1.0) was used for statistics. Results: Viremia persistence was associated with a higher level of baseline viremia, a higher rate of severe diseases and mortality within 28 days of follow-up. Viremia persistence was associated with elevation of certain exhaustion protein markers including TIM3, PDL1, LGALS9, LAG3 and IL2RA. With PLS-DA, we selected TIM3, PDL1, and LGALS9 into the exhaustion score modeling. A higher exhaustion score was associated with higher baseline viremia, persistent viremia, severe disease, and death (Figure). When compared to the lowest exhaustion score (1st quartile), the highest exhaustion score (4th quartile) was associated with elevation in proteins belonging to IL-18 signaling pathway, lung fibrosis, and immune evasion in COVID-19. The immune exhaustion level was not associated with the neutralization level. Conclusion: In participants with COVID-19, soluble exhaustion markers are associated with delayed viremia clearance, immune evasion independent of humoral immunity development, and adverse outcomes.

7.
Topics in Antiviral Medicine ; 30(1 SUPPL):41, 2022.
Article in English | EMBASE | ID: covidwho-1880388

ABSTRACT

Background: Camostat, a serine protease inhibitor, prevents activation of the SARS-CoV-2 spike protein and blocks SARS-CoV-2 infection in vitro. We studied the safety and antiviral and clinical efficacy of orally administered camostat in non-hospitalized adults with mild-moderate COVID-19. Methods: ACTIV-2/A5401 is a platform trial to evaluate therapies for non-hospitalized adults with mild-moderate COVID-19. In a Phase II portion of the study, participants were enrolled within 10 days of COVID-19 related symptom onset and randomized to camostat 200 mg orally every 6 hours for 7 days or the pooled placebo group. Objectives were to evaluate the safety and efficacy of camostat to reduce the duration of COVID-19 symptoms and increase the proportion of participants with SARS-CoV-2 RNA below the lower limit of quantification (LLoQ) from nasopharyngeal (NP) swabs on days 3, 7, and 14. Participants completed a study diary from day 0 to day 28 scoring COVID-19 symptoms as absent, mild, moderate, or severe. Results: Of the 224 participants enrolled from 54 US sites, 215 participants (108 camostat, 107 placebo) initiated study intervention and formed the modified intent-to-treat population. Fifty-four percent were female, >99% cis-gender, 85% White, 9% Black, and 51% Latinx. Median age was 37 years;47% reported ≤5 days of symptoms at study entry and 26% met the protocol definition of higher risk of progression to severe COVID-19. Most frequent symptoms on day 0 were cough (86%), fatigue (85%), nasal obstruction/congestion (71%) and body/muscle aches (71%). There was no significant difference between camostat and placebo arms in grade 3 or higher adverse events (7.4% vs. 6.5%, respectively). Median (Q1, Q3) time to symptom improvement was 9 days for both camostat (5, 20) and placebo (6, 19). There were no significant differences in the proportion of participants with NP SARS-CoV-2 RNA<="" div=""> Conclusion: Camostat was well-tolerated. Despite compelling in vitro data, camostat did not show evidence of antiviral or clinical efficacy in ACTIV-2/A5401. This highlights the critical importance of randomized controlled trials in the evaluation of therapies for COVID-19.

8.
Topics in Antiviral Medicine ; 30(1 SUPPL):39, 2022.
Article in English | EMBASE | ID: covidwho-1880219

ABSTRACT

Background: Molnupiravir, a prodrug of the broadly active, direct-acting antiviral, ribonucleoside analogue EIDD-1931, is a promising COVID-19 drug. Given the primary route of SARS-CoV-2 transmission through respiratory droplets we evaluated EIDD-1931 PK in saliva, nasal secretions and tears of patients with mild-to-moderate COVID-19 through the phase Ib/IIa AGILE platform (NCT04746183). Methods: Patients with PCR-confirmed SARS-CoV-2 infection, within 5 days of symptom onset with mild-to-moderate disease were randomised to oral molnupiravir 300, 600 or 800 mg twice daily. Plasma and non-plasma (saliva, nasal and tear swabs) samples were collected pre-dose, 0.5, 1, 2, and 4 hours post-dose on study days 1 and 5 and molnupiravir and EIDD-1931 measured by LC/MS (lower limit of quantification, 2.5 ng/mL). PK parameters were determined (Phoenix 64, WinNonlin, v. 8.3) and non-plasma:plasma (NP:P) ratios (based on AUC0-4) calculated. Relationships between paired non-plasma and plasma samples were evaluated by linear regression. Results: Twelve participants (n=4 per dose;75% female) completed the study contributing 111, 112 and 97 saliva, nasal and tear samples, respectively. Molnupiravir was detected in 11% of saliva samples [median (range) 4.86 ng/mL (2.63-31.44)] and not evaluated in swabs. Quantifiable EIDD-1931, following molnupiravir 300, 600 and 800 mg twice daily were i) saliva: 17.7 (2.8-133), 16.6 (2.9-469), 25.8 (4.0-230) ng/mL, ii) nasal swabs: 182 (18-1700), 136 (18-917), 295 (24-1879) ng/mL and iii) tears: 297 (24-1650), 176 (16-1260), 307 (32-2760) ng/mL. PK parameters are shown (Table 1). Median (range, CV%) pooled NP:P ratio for saliva was 0.03 (0.01-0.11, 60%;n=16). Nasal and tear ratios were 6-fold higher with values of 0.21 (0.05-0.73, 70%;n=17) and 0.22 (0.09-1.05, 92%;n=12), respectively. Non-plasma and plasma concentrations were significantly correlated (r2: 0.360-0.677;p<0.0001). Of measured saliva, nasal and tear samples, 6, 50 and 61%, respectively were within or above the EIDD-1931 EC90 against SARS-CoV-2 in primary human airway epithelia cultures (approximately 0.5-1 μ M ≈ 130-260 ng/mL). Conclusion: This is the first report of EIDD-1931 PK at sites of initial SARS-CoV-2 exposure in patients with COVID-19. Investigations of PK/PD relationships are warranted;however, these data suggest therapeutic concentrations are potentially achieved in nasal and tear compartments, but not saliva and have important implications for prophylactic coverage.

9.
Topics in Antiviral Medicine ; 30(1 SUPPL):176, 2022.
Article in English | EMBASE | ID: covidwho-1880117

ABSTRACT

Background: Casirivimab+imdevimab (hereinafter referred to as drug) remains vital in reducing hospitalization/death by 70% when administered early in the course of the infection. Our aim was to illustrate the mechanism of drug action in vivo and determine the magnitude of antiviral efficacy of various dose regimens given to outpatients with COVID-19, evaluating the presence of SARS-CoV-2 sero-antibody and ≥1 high-risk factor for developing severe COVID-19 illness as predictors of viral kinetics. Methods: Analysis data came from 2 clinical studies in SARS-CoV-2 infected outpatients with no or ≥1 risk factor for severe COVID-19 (NCT04425629 and NCT04666441), who received single dose of placebo or drug IV (300mg to 8g) or SC (600mg to 1.2g), had assessed viral load in nasopharyngeal swab and drug concentrations in serum (N=4500). The median number of viral load assessments per patient was 5 (range 1-8) within up to 14 days of follow-up time. Drug concentrations were predicted using the individual pharmacokinetic parameters yielded by a population model. The median patient age was 42 years, with similar proportion of males and females. The median viral load at baseline was 6.79 log10 copies/mL, and the median time of symptom onset was 3 days before study baseline. A standard target cell-limited model was used to estimate the time of infection and reconstruct viral kinetic profiles. Various relationships between exposure and resulting antiviral response were evaluated, where the drug could block de novo infection, increase the elimination rate of infected cells, or reduce viral production from infected cells. Results: The results support that the main mechanism of drug action is blocking de novo infection with an estimated decrease in the infectivity rate of 96.6%, for all dose regimens evaluated herein. High-risk factor for severe COVID-19 and baseline sero-antibody-positive/other status were associated with a 4.71% decrease and a 4.96% increase in the elimination rate of infected cells, respectively. The estimated median and 95th percentile of time to viral clearance (ie, viral count reaches below assay quantification limit) were 1.4 and 3.4 days shorter in drug vs placebo (median 10.6 vs 12.0 days, and 95th percentile 15.2 vs 18.6 days). Conclusion: All IV and SC casirivimab+imdevimab dose regimens evaluated herein showed similar near-maximal antiviral activity by blocking de novo infection;hence, shortening the time to virus clearance.

10.
British Journal of Haematology ; 197(SUPPL 1):174, 2022.
Article in English | EMBASE | ID: covidwho-1861257

ABSTRACT

Current therapy for adults with B-cell acute lymphoblastic leukaemia (B-ALL) remains suboptimal, despite good initial remission rates. Adults with relapsed or refractory B-ALL (R/R B-ALL) represent a challenge with historically poor outcome;the introduction of targeted agents has expanded options but there is no consensus management. Blinatumomab is a bispecific T-cell engager antibody construct against CD19 (Scottish Medicine consortium, SMC, approval February 2020);inotuzumab is a monoclonal anti-CD22 antibody conjugated to calicheamicin (SMC approval May 2018). Trial data have shown both agents improved remission rates and survival when compared with standard chemotherapy with manageable toxicity profiles, although adverse events including neurological toxicity and cytokine release syndrome (CRS) have been reported. We describe the experience of blinatumomab and inotuzumab in a BCSH level three unit from February 2017 to August 2021. Eleven patients-six male, five female, mean age 41.5 years (range 22-55) received a monoclonal antibody;blinatumomab ( n = 8) and inotuzumab ( n = 3). Ten had B-ALL and one had mixed lineage leukaemia (MLL). All patients were Philadelphia negative. Cytogenetic abnormalities were present in four cases-Inv(20), trisomy 21 (patient with Down syndrome), tetraploidy with isochromosome 17q and one with a complex karyotype. Further molecular information was available for nine cases, and all were negative for TCF3-PBX1 t(1;19), ETV6-RUNX1 t(12;21) and KMT2A rearrangements (including the case with MLL). Four patients received blinatumomab due to refractory BALL. Two (50%) went on to receive an allogeneic transplant in CR1 (one MRD negative and the other MRD below limit of quantification). Both patients were able to maintain a performance status of 0-1 pretransplant. One patient (25%) died due to SARS-COV-2 infection and the fourth patient's care was lost to follow-up. Four patients received blinatumomab due to relapsed BALL, two had undergone allogeneic transplant in CR1. Two patients (50%) died of progressive B-ALL. One patient is currently on UKALL 2011 regimen B maintenance B2 (comorbidities preclude allogeneic transplant), the other patient remains in molecular remission having failed lymphocyte collection for chimeric antigen (CAR) T-cell therapy. Three patients received inotuzumab for relapsed B-ALL. Two (66%) had a previous allogeneic transplant in CR1-one of whom went on to receive donor lymphocyte infusion (DLI) postinotuzumab while the other patient went on to have a second allogeneic transplant. The third patient relapsed on maintenance chemotherapy and has been referred for allogeneic transplant. Infective episodes occurred in 45% (all received blinatumomab) including one death from SARS-COV-2 pneumonitis. Following blinatumomab CRS and neurotoxicity (tonic-clonic seizures) occurred (both n = 1). No significant toxicities were observed in the three patients who received inotuzumab, although this likely reflects small patient numbers rather than a true difference between the two agents. Despite improved responses in R/R B-ALL with these therapies as single agents for the majority they do not offer cure. While toxicity was recorded it did not negatively impact PS. CAR T-cell therapy has demonstrated high initial remission rates in heavily treated B-ALL patients, including previous targeted therapy. Optimal sequencing of therapies remains to be defined alongside depth of response and duration of measurement.

11.
Journal of Aerosol Medicine and Pulmonary Drug Delivery ; 35(2):A9, 2022.
Article in English | EMBASE | ID: covidwho-1815951

ABSTRACT

The recent Covid-19 pandemic has drawn attention to the amount of fugitive aerosol that is emitted by nebulizers. The novel I-neb Advance Adaptive Aerosol Delivery (AAD) System incorporates an improved AAD algorithm intended to reduce treatment times compared with earlier AAD devices. We conducted an in vitro test to determine the amount of fugitive aerosol that is emitted from the I-neb Advance (AAD) System. Three production equivalent investigational I-neb Advance nebulizers fitted with nonmetering chambers were filled with 1.7mL of 2mg/mL salbutamol solution. The delivered dose was collected on a filter during operation into a simulated breathing pattern (Tv=500mL, I:E=1:1, f 15 bpm). A second filter was fixed 1 cm away from the exhalation port of the nebulizer with an extraction flow of 60 L/min. Each nebulizer was run in triplicate. Salbutamol on filters was quantitated by high performance liquid chromatography. The delivered doses had low co-efficients of variation, intra-nebulizer=0.83 to 3% and inter-nebulizer=0.77%. The fugitive aerosol was lower than the limit of quantification of the assay (0.18% of fill) in 2/3 of the tests. Measurable exhaled doses were all below 0.3% of the fill volume. The improved AAD algorithm used in the I-neb Advance (AAD) System delivered precise, reproducible doses with minimal fugitive aerosol emissions into a simulated breathing pattern. The minimization of fugitive aerosol emissions demonstrated by AAD nebulizers likely has an added relevance to aerosol treatment following the emergence of the Covid-19 pandemic. Key Message: The novel I-neb Advance (AAD) System was shown to deliver reproducible doses of drug with minimal (<0.3% of the nominal dose) fugitive aerosol emissions. This observation could be important in clinical situations where there is a need to minimise escaping aerosol from nebuliser devices during use.

12.
Turkish Journal of Biochemistry ; 46(SUPPL 2):27, 2021.
Article in English | EMBASE | ID: covidwho-1766748

ABSTRACT

BACKGROUND AND AIM: Dexamethasone is one of the most potent glucocorticoid. It is used in the various medical conditions such as multiple sclerosis, allergies, inflammation, asthma, dermatitis and shock. Recently, dexamethasone has been found to be beneficial in patients with COVID-19 pneumonia requiring supplemental oxygen or mechanical ventilation. It can cause serious adverse effects such as adrenal suppression, hyperglycemia, and cardiac arrhythmia. Therefore, monitoring of dexamethasone levels is important. Our aim in this study is to develop an LC-MS/MS method for dexamethasone. METHODS: Dexamethasone was detected with ABSciex API 3200 tandem mass spectrometery in positive electrospray ionization mode. The selected ion transitions for dexamethasone and internal standard were m/z 289.5/97.3 and m/z 339.1/113.2, respectively. Briefly, 100 μL of internal standard (17-hydroxyprogesterone-d8) and 4 mL of diethylether were added to 250 μL of sample, and vortexed for 1 minute, then centrifuged at 4000 g for 10 minutes. The supernatant was taken into tubes and evaporated at 40 °C under nitrogen gas. The residues were dissolved in 200 μL of methanol:water (1:1, v/v%) and 25 μL was injected. RESULTS: The calibration curve was linear between 1.95 and 2000 ng/mL (r2>0.99). The limit of quantitation for dexamethasone was 1.95 ng/mL. Total run time was 5 minutes. Intra- and inter-assay imprecision values were less than 9%. The mean extraction recovery was 92.8%, and the matrix effect ranged from 3.6% to 9.8%. CONCLUSIONS: A sensitive and reproducible tandem mass spectrometry method was developed for dexamethasone. The method can be used in the analysis of dexamethasone.

13.
Gastroenterology ; 160(6):S-475-S-476, 2021.
Article in English | EMBASE | ID: covidwho-1595033

ABSTRACT

BACKGROUND: Branch duct (BD)-IPMNs with increased risk for malignant transformation are typically treated with surgical resection, and alternate therapies are needed for patients with prohibitive risks for perioperative complications. Injection of cysts with paclitaxel may prevent or reverse transformation, but current formulations are not retained in cysts to provide durable benefit. A Submicron Particle formulation of Paclitaxel (SPP) has been designed to avoid clearance into the systemic circulation and effectively provides a depot effect releasing the drug at constant saturation levels. In this initial study of EUS-guided fine needle injection (FNI) with SPP we evaluated safety, tolerability, pharmacokinetics, and cyst response in BD-IPMNs. METHODS: A diagnosis of BD-IPMNs was confirmed by EUSguided confocal laser endomicroscopy and cyst fluid next generation sequencing. Subjects received EUS-FNI of SPP (15mg/mL concentration) at volumes equal to the aspirated cyst fluid as part of an ongoing clinical trial [NCT03188991] (Study was interrupted due to COVID-19 pandemic). This report covers 5 of the study subjects enrolled at one site. SPP was administered on two occasions 12 weeks apart in 4/5 subjects and once in 1 subject. CT Scans were performed at 0, 12, and 24 weeks to assess changes in cyst size. RESULTS: The mean6standard deviation duration of follow-up from 1st EUS-FNI was 37.3±19.8 weeks. The mean size on CT-Scan of BD-IPMNs at time 0 weeks (1st EUS-FNI) was 3.360.8 cm, 12 weeks (2nd EUS-FNI) was 3.02±1.2 cm, and 24 weeks was 3.15±1.8 cm (Table 1). The mean dosage of SPP injected by EUS-FNI was 75±39 mg for 1st dose and 40.6±15.1 mg for 2nd dose. No dose limiting toxicities, study-related serious adverse events, or clinically significant changes in blood work were observed. The paclitaxel levels (PK) in plasma and cyst fluid is shown in Figure 1. Systemic paclitaxel concentration did not exceed 1 ng/mL at any point post-administration, falling below lower limit of quantitation (25 pg/mL) within, at most, 4 weeks. Cyst fluid analysis confirmed sustained presence of SPP for at least 12 weeks. At baseline evaluation, 4 of 5 subjects had GNAS mutations in cyst fluid (Table 1). In total, DNA mutations (KRAS or GNAS) were not detectable in two of 4 (50%) subjects after EUS-FNI with SPP (Table 1);both subjects (Figure 1) had a dose-dependent high intracystic concentration (> 1000 ng/mL) of SPP immediately prior to 2nd EUS-FNI (week 12). CONCLUSION: EUS-FNI of intracystic SPP appears to be safe and tolerable in patients with BD-IPMNs. SPP is likely retained in these cysts up to 12 weeks in a dose-dependent manner and higher doses are associated with regression of mutations that are specific for BD-IPMNs. Future studies with additional injections and longer-term follow-up are needed to understand the durability of the benefits observed.(Table presented)(figure presented)

14.
Blood ; 138:3724, 2021.
Article in English | EMBASE | ID: covidwho-1582338

ABSTRACT

Humoral and cellular adaptive immunity likely contribute to protection against coronavirus disease 2019 (COVID-19). Neutralizing antibodies and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-specific T cells have been detected in convalescent and immunized immunocompetent individuals. Chronic lymphocytic leukemia (CLL) and its treatment, particularly anti-CD20 monoclonal antibodies and Bruton tyrosine kinase inhibitors (BTKis), blunt the antibody response to vaccines. To understand the immunogenicity of COVID-19 vaccination in patients with CLL, assessment of the T-cell response is urgently needed. Between December 22, 2020 and May 7, 2021, 57 patients with CLL were immunized with either 2 doses of BNT162b2 (n = 30) or mRNA-1273 (n = 25) or 1 dose of Ad26.COV2.S (n = 2). Qualitative and semi-quantitative anti-spike antibodies were measured with serology tests authorized by the FDA under Emergency Use Authorization. A positive humoral response to vaccination was defined as the detection of anti-spike antibodies. Ultra-deep TCRß sequencing (Adaptive Biotechnologies) was performed on total peripheral blood mononuclear cells collected before and after vaccination. These data were analyzed in the immunoSEQ Analyzer. Differential abundance was calculated using the beta-binomial model and two-sided α=.05. SARS-CoV-2 spike-specific T cells were identified in the T-MAP COVID ImmuneCODE database. A positive cellular response to vaccination was defined as significant expansion of ≥1 spike-specific clonotype. Anti-spike antibodies were detected in 61% (35/57) of patients at a median (interquartile range, IQR) of 45 (30-56) days after the last dose of vaccine. The median (IQR) antibody titer was 19.1 U/mL (3.6-150.9) among 27 patients with humoral response. There were 4 patients with titers above the upper limit of quantification (>250 U/mL) and 4 patients who had qualitative testing only. The rate of humoral response was 71% (15/21) in treatment naïve (TN) patients, 57% (16/28) in patients treated with BTKi, and 0% (0/4) in patients treated with venetoclax and anti-CD20 monoclonal antibody (mAb). Among 16 BTKi-treated patients with anti-spike antibodies, 2 interrupted BTKi during the vaccination period. One patient treated with venetoclax monotherapy and 3 previously treated patients had detectable anti-spike antibodies. The immediate prior therapies were acalabrutinib >1 year before vaccination for 2 patients and chemoimmunotherapy >8 years before vaccination for 1 patient. Vaccination with mRNA-1273 induced numerically higher titers compared to BNT162b2 (median 85.5 U/mL versus 11.0 U/mL;P=.1), but the rate of seroconversion was not significantly different (P=.4). No patients reported a history of SARS-CoV-2 infection and anti-nucleocapsid antibodies were negative in 100% (50/50) of patients tested. Circulating CD8 + T cells increased from a median (IQR) of 13.2% (7.8-18.8) at baseline to 14.3% (8.8-20.6) after vaccination (P=.015). CD3 + and CD4 + T cells did not significantly change. TCRß sequencing results are available in 7 patients (Table). The median (IQR) number of productive templates, which corresponds to the number of T cells sequenced in each sample, was 447,805 (377,738-503,097). Cellular response was observed in 57% (4/7) of patients. A total of 10 expanded spike-specific clonotypes were identified and ranged between 1 and 6 clonotypes per patient. The cumulative frequency of spike-specific clonotypes after vaccination ranged between 0.0036% and 1.55% per patient. None of these clonotypes were found at baseline despite the large number of productive templates generated in each sample. Spike-specific T cells were detected in 50% (2/4) of patients with anti-spike antibodies and 67% (2/3) of patients without seroconversion. In conclusion, patients with CLL have impaired humoral and cellular responses to COVID-19 vaccination. Seroconversion occurred less often in patients treated with BTKi than TN patients and was absent in patients treated with venetoclax and anti-CD20 mAb. Cellular responses w re seen in the absence of humoral responses. TCRß sequencing is ongoing in additional patients. Updated data will be presented at the meeting. [Formula presented] Disclosures: Sun: Genmab: Research Funding. Wiestner: Merck: Research Funding;Nurix: Research Funding;Genmab: Research Funding;Verastem: Research Funding;Acerta Pharma: Research Funding;Pharmacyclics: Research Funding.

15.
Blood ; 138:47, 2021.
Article in English | EMBASE | ID: covidwho-1582181

ABSTRACT

Background Patients with hematologic malignancy have a higher risk of death from COVID-19 compared to the general population. A blunted immune response from both the underlying disease and applied treatment may contribute to development of more severe forms of COVID-19, absence of seroconversion, prolonged viral shedding, and might also impair humoral vaccine response. Factors influencing efficacy of SARS-CoV-2 vaccines in this patient population are still insufficiently explored. Methods We prospectively enrolled 143 patients with malignant or non-malignant hematologic diseases from University Hospital Centre Zagreb vaccinated between January and June 2021 with either mRNA-1273 (Moderna), BNT162b2 mRNA (Pfizer-BioNTech), or ChAdOx1 nCoV-19 (Oxford-AstraZeneca) vaccines. A qualitative assay against SARS-CoV-2 nucleocapsid antigen was used to detect prior infection;these patients (n=23) were excluded from the final analysis. Humoral response following vaccination was monitored using serological immunoassay registered for quantitative measurement of serum anti-SARS-CoV-2 RDB-spike protein antibodies. Both electrochemiluminescent assays performed by Cobas e801 analyzer (Roche Diagnostics, Mannheim, Germany) detect total antibodies (including IgG). Response was recorded after the first and second doses. A positive response was defined as > 0.8 U/mL. Upper and lower limits of quantification were 0,4 U/mL and 250 U/mL respectively. We reviewed patient records for demographics, underlying hematological diseases, current treatment, the total number of lines of therapy received, IgG levels, application of anti-CD20 monoclonal antibodies (mAbs) and corticosteroids in the last 6 months before vaccination, and subsequent SARS-CoV-2 infection. Inter-group comparisons were performed with Mann-Whitney U, χ 2, or Fisher's exact test as appropriate. ROC curve analysis was used to find optimized cut-off values of numerical variables regarding response to the second dose. P values <0.05 were considered statistically significant. MedCalc statistical software v 20.008 was used for all analyses. Results We evaluated a total of 120 patients who received at least one dose. Patient characteristics are summarized in Table 1. The majority received the Pfizer-BioNTech vaccine (66.7%), followed by Oxford-AstraZeneca (24.2%) and Moderna (9.2%). Data on humoral response after the first dose was available in 66 patients, among whom 20 (33%) achieved response with median specific IgG levels 6.1 U/mL. Response after the second dose was available in 90 patients;58 (64.4%) achieved response with median specific IgG levels 250 U/mL. The second dose significantly improved response both in terms of achieved response (P=0.031) and specific IgG levels (P<0.001). There were no significant differences in response or specific IgG levels regarding the type of the vaccine (P>0.05). Lower response rates after the second dose were achieved in patients aged >67 years (P<0.001;response in 32.4% vs. 83.9%), with specific diagnosis (P=0.002, driven by response in patients with non-Hodgkin's lymphoma (NHL;response in 29.2% NHL vs. 77.3% non-NHL) and chronic myeloid leukemia (CML;100% response in CML vs. 61.4% non-CML)), those receiving active treatment (50% vs. 88%;P<0.001), no prior hematopoietic stem cell transplantation (HSCT;51% vs. 93%;P<0.001) and prior anti-CD20 mAbs therapy (4% vs. 85%;P<0.001). Corticosteroid therapy (>120 mg prednisone equivalent dose) did not influence the response significantly (response in 88.9% vs. 42.1%;P=0.056), and neither did steroid type. Four (3,3%) patients tested positive for SARS-CoV-2 after vaccination, 2 of which had no humoral response, and 2 had received only one dose. Three patients required in-hospital treatment and oxygen supplementation. Conclusions Patients with hematologic diseases have lower serological response rates to SARS-CoV-2 vaccines than those previously reported in clinical trials. Our results also suggest they benefit from receiving both doses with no significant difference between vaccine types. Those in active treatment, no prior HSCT, diagnosed with NHL, and receiving anti-CD20 mAb seem more likely to be seronegative after receiving both doses. However, the present study did not examine potential confounding effects between these factors and these findings should be elaborated further in larger patient cohorts. [Formula presented] Disclosures: Aurer: Novartis: Consultancy, Honoraria;Janssen: Consultancy, Honoraria;Swixx/BMS: Honoraria;sanofi genzyme: Consultancy, Honoraria;Teva/Pilva: Honoraria;Abbvie: Consultancy, Honoraria;Eusapharma: Consultancy, Honoraria;Amgen: Consultancy, Honoraria;takeda: Consultancy, Honoraria. Durakovic: Takeda, Novartis, Genyzme: Honoraria.

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