Safety and efficacy of midazolam nasal spray for the treatment of intermittent bouts of increased seizure activity in the epilepsy monitoring unit: A double-blind, randomized, placebo-controlled trial

OBJECTIVE

Midazolam nasal spray (MDZ-NS) is indicated for acute treatment of intermittent, stereotypic episodes of frequent seizure activity (ie, seizure clusters, acute repetitive seizures) that are distinct from a patient's usual seizure pattern, in patients 12 years of age and older with epilepsy. This trial evaluated safety and efficacy of MDZ-NS in patients with epilepsy who were admitted to the epilepsy monitoring unit for seizure characterization/presurgical evaluation.

METHODS

In this randomized, double-blind, placebo-controlled phase 3 trial (P261-301; NCT01999777), eligible patients with ≥2 seizures in the 6-hour window preceding trial medication administration for whom treatment was appropriate based on investigator's judgment were randomized (1:1) to MDZ-NS 5 mg or placebo. Efficacy outcomes were proportion of patients seizure-free for 6 hours after treatment and time to first seizure within 6 hours. Safety and tolerability outcomes included treatment-emergent adverse events (TEAEs).

RESULTS

Sixty-two patients were randomized (MDZ-NS n = 31; placebo n = 31), received trial medication, and completed the trial. A higher proportion of patients on MDZ-NS than placebo were seizure-free for 6 hours following treatment (54.8% vs 38.7%); however, the 16.1% difference was not statistically significant (P = .1972). The Kaplan-Meier curve of time to first seizure showed separation of both groups in favor of MDZ-NS from ~1.5 hours post-dose and throughout the 6-hour Treatment phase. Median time to first seizure was not estimable for MDZ-NS (>50% of patients had no seizure) and 3.9 hours for placebo (P = .1388). TEAEs with MDZ-NS were generally comparable to those with placebo. There were no deaths, serious TEAEs, or discontinuations due to TEAEs.

SIGNIFICANCE

Although the observed treatment difference may be clinically meaningful, statistical significance was not demonstrated. Results suggest that MDZ-NS 5 mg may provide improvement over placebo, with efficacy maintained for ≥6 hours post-dose. MDZ-NS was well tolerated in this population.

Using quality improvement to implement the CNS/AAN quality measure on rescue medication for seizures

OBJECTIVE

A multidisciplinary quality improvement (QI) team was established to conduct analysis of data for prescribed seizure rescue medication doses from January 2013 to December 2015 to identify and improve inappropriately low dose prescriptions. The QI team identified areas of focus for improvement opportunities and developed the project objective based on the 2017 American Academy of Neurology (AAN) and Child Neurology Society (CNS) quality measure.

METHODS

Within a freestanding children's hospital, the QI team developed key drivers and implemented interventions, such as the midazolam prefilled syringe program with use of standardized dosing, electronic chart tools, monthly pharmacy review of all underdosed prescriptions, and provider and nursing education. The team created an automated monthly report to monitor prescribed seizure rescue medication dosing compliance. The year 2015 was used as the preliminary data baseline period with an average noncompliance rate of 3.5%.

RESULTS

From January 2016 to December 2019, the team has decreased and sustained the noncompliance rate to an average of 0.38%. The data for the project included 12,975 seizure rescue medication prescribed by a neurology provider from January 2015 to December 2019. Compliance with properly dosed diazepam orders continues to be the largest area of opportunity. The data demonstrated a centerline shift in January 2019, moving the baseline average of 7.2% noncompliance to the current average rate of 0.22%. In comparison, underdosed midazolam orders occurred at an average rate of 0.037% in the same timeframe.

SIGNIFICANCE

Using quality improvement methodologies, the team successfully and substantially decreased provider prescribed and signed underdosed rescue medication orders by an average of 89%. This QI project demonstrates successful implementation and improvement addressing the AAN/CNS quality measure of proper rescue seizure treatment dosing.

Folic acid rescues all-trans retinoic acid-induced anorectal malformations in rats

BACKGROUND

To investigate whether folic acid (FA) can rescue anorectal malformations (ARMs) induced by all-trans retinoic acid (ATRA) in rats.

METHODS

Pregnant Sprague-Dawley rats were randomly divided into three groups. In the model group, rats were administered ATRA (110 mg/kg) by gavage on the 10th day of gestation (E10.5). Rats in the rescue group were administered FA (40 mg/kg) by gavage 0.5 and 12 hr after treatment with ATRA. All fetuses were harvested on E20.5 using cesarean section and examined for ARMs. We recorded the weight, body length, tail length, and associated malformations of all the embryos. Hematoxylin and eosin staining was used to analyze the histopathology of the fetuses.

RESULTS

Control rats did not show any abnormalities. ARMs, tail deformities (less than half of normal length), and neural tube defects were found in 97.98% (97/99), 92.93% (92/99), and 32.32% (32/99) of the rats in the model group, respectively. The incidence of ARMs and tail deformities were 48.57% (51/105) and 35.24% (37/105), respectively, in the rescue rats; no neural tube defects were observed in these rats. The weight, body length, and tail length of the fetal rats in the rescue group were more than those in the model group, but less than those in the control group.

CONCLUSION

Taken together, FA rescued ARMs induced by ATRA in rats. Thus, FA may reduce the incidence of associated malformations and improve the growth and development of fetal rats.

N-Acetyl Cysteine Modulates the Inflammatory and Oxidative Stress Responses of Rescued Growth-Arrested Dental Pulp Microtissues Exposed to TEGDMA in ECM

Dental pulp is exposed to resin monomers leaching from capping materials. Toxic doses of the monomer, triethyleneglycol dimethacrylate (TEGDMA), impact cell growth, enhance inflammatory and oxidative stress responses, and lead to tissue necrosis. A therapeutic agent is required to rescue growth-arrested tissues by continuing their development and modulating the exacerbated responses. The functionality of N-Acetyl Cysteine (NAC) as a treatment was assessed by employing a 3D dental pulp microtissue platform. Immortalized and primary microtissues developed and matured in the extracellular matrix (ECM). TEGDMA was introduced at various concentrations. NAC was administered simultaneously with TEGDMA, before or after monomer addition during the development and after the maturation stages of the microtissue. Spatial growth was validated by confocal microscopy and image processing. Levels of inflammatory (COX2, NLRP3, IL-8) and oxidative stress (GSH, Nrf2) markers were quantified by immunoassays. NAC treatments, in parallel with TEGDMA challenge or post-challenge, resumed the growth of the underdeveloped microtissues and protected mature microtissues from deterioration. Growth recovery correlated with the alleviation of both responses by decreasing significantly the intracellular and extracellular levels of the markers. Our 3D/ECM-based dental pulp platform is an efficient tool for drug rescue screening. NAC supports compromised microtissues development, and immunomodulates and maintains the oxidative balance.

Mission Abort Policy for Systems with Observable States of Standby Components

For some critical applications, successfully accomplishing the mission or surviving the system through aborting the mission and performing a rescue procedure in the event of certain deterioration condition being satisfied are both pivotal. This has motivated considerable studies on mission abort policies (MAPs) to mitigate the risk of system loss in the past several years, especially for standby systems that use one or multiple standby sparing components to continue the mission when the online component fails, improving the mission success probability. The existing MAPs are mainly based on the number of failed online components ignoring the status of the standby components. This article makes contributions by modeling standby systems subject to MAPs that depend not only on the number of failed online components but also on the number of available standby components remaining. Further, dynamic MAPs considering another additional factor, the time elapsed from the mission beginning in the event of the mission abort decision making, are investigated. The solution methodology encompasses an event-transition based numerical algorithm for evaluating the mission success probability and system survival probability of standby systems subject to the considered MAPs. Examples are provided to demonstrate the benefit of considering the state of standby components and elapsed operation time in obtaining more flexible MAPs.

Safety and tolerability associated with chronic intermittent use of diazepam buccal film in adult, adolescent, and pediatric patients with epilepsy

Objective

Diazepam buccal film (DBF) is in development for treatment of patients experiencing bouts of increased seizure activity. We assessed safety, tolerability, and usability of self‐ or caregiver‐administered DBF in the outpatient setting.

Methods

Patients aged 2‐65 years needing treatment with a rescue benzodiazepine at least once monthly were eligible for the study. DBF (5‐17.5 mg) was dispensed based on age and body weight. Patients/caregivers administered DBF for up to five seizure episodes per month. Adverse events (AEs) and usability assessments were recorded after the first dose, then every 3 months.

Results

Onehundred eighteen patients who used ≥1 DBF dose (adults, n = 82; adolescents, n = 19; children, n = 17) were enrolled. Eleven treatment‐related AEs (10 being mild or moderate in severity) occurred in nine (7.6%) patients over a mean of 243 days of follow‐up. No patient discontinued participation because of AEs. Mild local buccal discomfort, buccal swelling, and cheek skin sensitivity were reported by one patient each. Twenty‐two serious AEs were reported; one was treatment‐related. The three deaths reported, all unrelated to DBF, resulted from seizures or seizure with brain malignancy. Self‐administration by adults was attempted on 23.6% (188/795) of use occasions. Administration of DBF occurred under ictal or peri‐ictal conditions on 49.5% (538/1087) of use occasions, and DBF was successfully administered on a first or second attempt on 96.6% (1050/1087) of use occasions. Overall, patients received their dose of DBF on 99.2% (1078/1087) of use occasions. A second DBF dose was required within 24 hours after the first dose on 8.5% (92/1087) of use occasions.

Significance

In this observational study of chronic intermittent use, DBF was easy to administer, safe, and well tolerated in adult, adolescent, and pediatric patients with epilepsy experiencing seizure emergencies. DBF can be readily self‐administered by adults with epilepsy, as well as successfully administered by a caregiver in seizure emergencies.

Case Report: Opportunities for Treatment of Severe COVID-19 Patients-Lessons From a Death Case

With the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, the incidence of coronavirus disease (COVID-19) increases each day. To date, there is no specific anti-SARS-CoV-2 drug. The usual approach to treating COVID-19 is treating its symptoms. However, this approach is limited by the different conditions of each area. We treated a 57-year-old man who was initially diagnosed with a severe type of the infection, but he progressed to a critical condition and eventually died. We learned valuable lessons from this case. The first lesson is the need to use immediate invasive mechanical ventilation if there is no obvious improvement after using non-invasive ventilation for several hours, which directly affects the prognosis. Another lesson is the risk involved in transferring severe COVID-19 patients. In the process of transfer, various threats may be encountered at any time. Thus, accurate assessment of the patient's condition and strict medical conditions are highly required. During the patient's 25-day treatment, we performed cardiopulmonary resuscitation twice. Currently, many patients require invasive mechanical ventilation and transfer to a superior hospital. We hope our findings will provide some advice and help for treating severe and critical COVID-19 cases.

Legal Complexities of Entry, Rescue, Seizure and Disposal of Disaster-Affected Companion Animals in New Zealand

With the increasing societal expectation that animals are afforded greater protection in emergencies, the legal process from entering a property to rescuing a companion animal, through to how to dispose of such animals if they remain unclaimed has not been well examined in New Zealand. It is hypothesised that the legal framework for such a response is flawed. In this study, each phase of animal disaster rescue is evaluated against four key statutes that may apply in each phase, in that does any statute provide clear end-to-end provisions with clear legal authority to do so? The study found that all statutes evaluated contained flaws and that the current legal provisions are insufficient to provide clear authority for the sequential process of undertaking the rescue of animals during emergencies. A major flaw was discovered in the Civil Defence Emergency Management Act 2002, a key statute, that provided for the seizure of property and animals but omitted a procedure for the disposal of such seized things leaving them all in legal limbo. It is recommended that animal disaster laws be updated to be more animal inclusive. The method also may be applicable to assist evaluating animal disaster management legal frameworks in other countries.

Having Infants in the Family Group Promotes Altruistic Behavior of Marmoset Monkeys

The common marmoset (Callithrix jacchus) has attracted much attention as a useful model for studying social behaviors [1-3]. They naturally live in a monogamous family group and exhibit cooperative breeding [4], in which parents and older siblings help to carry infants less than 2 months old [5-7]. Marmoset parents also transfer foods to their offspring, a process that may help them learn the food diet [8]. Furthermore, marmosets show spontaneous altruistic behaviors, such as providing food to non-reciprocating and genetically unrelated individuals [9]. These social habits indicate that marmosets may be a useful non-human primate model for studying parenting and altruistic behaviors, as well as underlying neural mechanisms. Using a novel rescue paradigm, we found that marmoset parents and older siblings showed strong motivation to rescue trapped young infants but not juvenile marmosets beyond 2 months of age, and infant calls alone could trigger these parents' rescue behaviors. The marmoset parents showed little rescue of each other, but young infants or infant calls could also induce such parents' mutual rescue. Moreover, all these infant- and mate-rescue behaviors depended on currently having young infants in the family group. Functional MRI studies on awake adult marmosets showed that calls from young infants, but not juvenile marmosets, elicited a large-scale activation of specific brain areas including auditory and insular cortices, and such activation was absent in marmosets not living with infants. Thus, such infant-induced modification of neural activity offers a window for examining the neural basis of altruistic behaviors in marmoset monkeys.

Allosteric targeting of the FFA2 receptor (GPR43) restores responsiveness of desensitized human neutrophils

The G protein‐coupled free fatty acid receptor 2 (FFA2R) is highly expressed on neutrophils and was previously described to regulate neutrophil activation. Allosteric targeting of G protein‐coupled receptors (GPCRs) is increasingly explored to create distinct pharmacology compared to endogenous, orthosteric ligands. The consequence of allosteric versus orthosteric FFA2R activation for neutrophil response, however, is currently largely elusive. Here, different FFA2R desensitization profiles in human neutrophils following allosteric or orthosteric activation are reported. Using a set of neutrophil functional assays to measure calcium flux, pERK1/2, chemotaxis, cellular degranulation, and oxidative burst together with holistic and pathway‐unbiased whole cell sensing based on dynamic mass redistribution, it is found that the synthetic positive allosteric modulator agonist 4‐CMTB potently activates neutrophils and simultaneously alters FFA2R responsiveness toward the endogenous, orthosteric agonist propionic acid (C3) after homologous and heterologous receptor desensitization. Stimulation with C3 or the hierarchically superior chemokine receptor activator IL‐8 led to strong FFA2R desensitization and rendered neutrophils unresponsive toward repeated stimulation with C3. In contrast, stimulation with allosteric 4‐CMTB engaged a distinct composition of signaling pathways as compared to orthosteric receptor activation and was able to activate neutrophils that underwent homologous and heterologous desensitization with C3 and IL‐8, respectively. Moreover, allosteric FFA2R activation could re‐sensitize FFA2 toward the endogenous agonist C3 after homologous and heterologous desensitization. Given the fact that receptor desensitization is critical in neutrophils to sense and adapt to their current environment, these findings are expected to be useful for the discovery of novel pharmacological mechanisms to modulate neutrophil responsiveness therapeutically.

Mutagenic Analysis of Hazara Nairovirus Nontranslated Regions during Single- and Multistep Growth Identifies both Attenuating and Functionally Critical Sequences for Virus Replication

Hazara nairovirus (HAZV) is a member of the family Nairoviridae in the order Bunyavirales and closely related to Crimean-Congo hemorrhagic fever virus, which is responsible for severe and fatal human disease. The HAZV genome comprises three segments of negative-sense RNA, named S, M, and L, with nontranslated regions (NTRs) flanking a single open reading frame. NTR sequences regulate RNA synthesis and, by analogy with other segmented negative-sense RNA viruses, may direct activities such as virus assembly and innate immune modulation. The terminal-proximal nucleotides of 3' and 5' NTRs exhibit extensive terminal complementarity; the first 11 nucleotides are strictly conserved and form promoter element 1 (PE1), with adjacent segment-specific nucleotides forming PE2. To explore the functionality of NTR nucleotides within the context of the nairovirus multiplication cycle, we designed infectious HAZV mutants bearing successive deletions throughout both S segment NTRs. Fitness of rescued viruses was assessed in single-step and multistep growth, which revealed that the 3' NTR was highly tolerant to change, whereas several deletions of centrally located nucleotides in the 5' NTR led to significantly reduced growth, indicative of functional disruption. Deletions that encroached upon PE1 and PE2 ablated virus growth and identified additional adjacent nucleotides critical for viability. Mutational analysis of PE2 suggest that its signaling ability relies solely on interterminal base pairing and is an independent cis-acting signaling module. This study represents the first mutagenic analysis of nairoviral NTRs in the context of the infectious cycle, and the mechanistic implications of our findings for nairovirus RNA synthesis are discussed.IMPORTANCE Nairoviruses are a group of RNA viruses that include many serious pathogens of humans and animals, including one of the most serious human pathogens in existence, Crimean-Congo hemorrhagic fever virus. The ability of nairoviruses to multiply and cause disease is controlled in major part by nucleotides that flank the 3' and 5' ends of nairoviral genes, called nontranslated regions (NTRs). NTR nucleotides interact with other virus components to perform critical steps of the virus multiplication cycle, such as mRNA transcription and RNA replication, with other roles being likely. To better understand how NTRs work, we performed the first comprehensive investigation of the importance of NTR nucleotides in the context of the entire nairovirus replication cycle. We identified both dispensable and critical NTR nucleotides, as well as highlighting the importance of 3' and 5' NTR interactions in virus growth, thus providing the first functional map of the nairovirus NTRs.

Tofacitinib for Rescue Therapy in Acute Severe Ulcerative Colitis: A Real-world Experience

BACKGROUND

Acute severe ulcerative colitis is a high stakes event with significant numbers still requiring emergent colectomy, representing a need to establish alternative medical management options. We report a case series of tofacitinib as rescue therapy in biologic-experienced patients with acute severe ulcerative colitis.

METHODS

Four patients were identified over a 1-year period at our institution who initiated tofacitinib for acute severe ulcerative colitis. All four had previously failed at least two biologics, including infliximab, and were failing high-dose oral prednisone therapy before admission. All patients had Mayo disease activity index of at least 10 at admission. After no significant improvement despite receiving a minimum of 3 days of intravenous methylprednisolone and based on elevated Ho and Travis indices at Day 3, patients were offered rescue tofacitinib for induction of remission, or colectomy. Standard induction of tofacitinib was used [10 mg twice daily], and one patient was escalated to 15 mg twice daily after inadequate response.

RESULTS

All patients experienced improvement in objective symptoms and laboratory markers, and were discharged without colectomy on tofacitinib as maintenance therapy and prednisone taper; 30-day and 90-day colectomy rates on tofacitinib maintenance therapy were zero and 90-day readmission rate was also zero. Two of four patients achieved steroid-free remission on maintenance tofacitinib monotherapy based on clinical symptoms and follow-up endoscopy. No major adverse reaction was reported during induction or maintenance therapy.

CONCLUSIONS

Tofacitinib may be an acceptable rescue agent in biologic-experienced patients with acute severe ulcerative colitis. Tofacitinib may also be safely continued as maintenance therapy once remission has been achieved.

Human factors studies of a prefilled syringe with stable liquid glucagon in a simulated severe hypoglycemia rescue situation

Background: Two human factors studies evaluated whether a stable liquid formulation of glucagon in a prefilled syringe (G-PFS) could be safely and effectively administered and evaluated the effectiveness of the product label guide and instructions-for-use (IFU). Research design and methods: In a formative study, 11 participants received orientation with the G-PFS instructional materials and performed a single unaided rescue attempt. In the validation study, 75 adult and adolescent participants received training or familiarized themselves with the G-PFS IFU, Label Guide, and device. All participants returned 1 week later to perform a single unaided rescue attempt of a simulated person with diabetes suffering from an emergency severe hypoglycemic event. Results: The formative study resulted in a 100% success rate across all rescue dose attempts. The validation study resulted in 74/75 (99%) of participants successfully using the G-PFS to administer the full glucagon rescue dose, and validated that intended users could learn from, comprehend, and recall the G-PFS instructions to successfully use the product. Conclusion: The G-PFS provides a familiar, easy-to-use alternative to currently marketed lyophilized glucagon kits for treating severe hypoglycemia. The G-PFS IFU and Label Guide enable even untrained users to successfully administer a full rescue dose of stable liquid glucagon.

Efficacy and toxicity of mustargen, vincristine, procarbazine and prednisone (MOPP) for the treatment of relapsed or resistant lymphoma in cats

OBJECTIVES

The aims of this study were to evaluate the safety of mustargen, vincristine, procarbazine and prednisone (MOPP) chemotherapy in the treatment of relapsed or refractory feline lymphoma, and to determine the overall response rate and median remission time with this protocol.

METHODS

The medical records of 38 cats with relapsed or refractory lymphoma treated with MOPP chemotherapy at three institutions (University of Pennsylvania, the Animal Medical Center, and VCA Western Veterinary Specialist and Emergency Centre) were examined. Information evaluated included patient signalment, feline immunodeficiency virus/feline leukemia virus status, anatomic location(s) of lymphoma, prior protocols (type and number), MOPP doses, MOPP response, remission duration, hematologic and biochemical parameters, and owner-reported adverse effects.

RESULTS

Overall, 70.3% of cats responded to MOPP chemotherapy. Among the responders, the median remission duration was 166 days. The most common adverse effects were neutropenia and gastrointestinal upset, which were reported in 18.4% of cats. In 55.3% of cats, no adverse effects were reported. In total, 30.8% of responders continued to respond 6 months following the initiation of MOPP, and 15.4% maintained a response 1 year after starting MOPP.

CONCLUSIONS AND RELEVANCE

MOPP is a safe protocol for the treatment of relapsed or refractory feline lymphoma, with a promising overall response rate and median remission time.

Otoscopy and aural cytological findings in a population of rescue cats and cases in a referral small animal hospital in England and Wales

OBJECTIVES

Otitis externa is seen clinically in cats, although studies investigating this condition within the UK are lacking. The objective of this study was to investigate the prevalence of Otodectes cynotis mites and microbial infection in the ear canals of cats in various rescue centres and a referral hospital.

METHODS

Otoscopy was performed in 332 cats. Otoscopic findings were noted, including the gross visualisation of Otodectes species. A sample of cerumen was collected for cytological evaluation and a cerumen smear for detection of Otodectes mites if there was a large amount of aural exudate present.

RESULTS

O cynotis infestation was noted in 3/341 cats (0.9%, 95% confidence interval [CI] 0.3-2.6). A total of 129/341 (37.8%; 95% CI 32.7-43.0) cats were found to have Malassezia species within one or both ears. Bacteria were found unilaterally in 9/341 (2.6%; 95% CI 1.4-4.9) cats. Analysis of the cytological findings showed an increased likelihood for Malassezia species to be present as age increased (n = 293; Pearson r = 0.204, P <0.001). There was also an increased likelihood of finding Malassezia species in both ears if found within one ear (n = 327; r = 0.499, P <0.001). There was a positive correlation between the number of Malassezia organisms and the quantity of aural exudate (n = 338; r = 0.778, P <0.001). Cats in which Otodectes species infestation were noted (n = 3) had moderate or large quantities of cerumen.

CONCLUSIONS AND RELEVANCE

This study shows that there was a low prevalence of O cynotis in this cohort of cats. In normal cats it was not unusual to find Malassezia microorganisms upon aural cytology, bacteria were noted far less frequently and in two cats this was associated with underlying anatomical pathology.

Picture Perfect Pups: How Do Attributes of Photographs of Dogs in Online Rescue Profiles Affect Adoption Speed?

To increase the public's awareness of and exposure to animals needing homes, PetRescue, Australia's largest online directory of animals in need of adoption, lists all currently available animals from rescue and welfare shelters nationwide. The current study examined the photographs in the PetRescue online profiles of the three most common breeds within these data, namely, Staffordshire bull terriers (n = 3988), Labrador retrievers (n = 2246), and Jack Russell terriers (n = 2088), to identify the inferred preferences of potential adopters. By investigating the attributes of these photographs, we were able to identify visual risk factors associated with protracted lengths of stay (LOS). The longest stays were associated with dogs with erect ears and those photographed in a natural environment, i.e., 18.32 days and 19.57 days, respectively. Dogs photographed in a kennel and with mouths closed had the shortest LOS, i.e., 11.54 d and 14.44 d, respectively. Heightened awareness of the roles of photographic attributes in generating interest among potential adopters may increase the speed of adoption by guiding the creation of online profiles and selection of photos to optimise the promotion of dogs at risk of long stays.

Importing rescue dogs into the UK: reasons, methods and welfare considerations

BACKGROUND

Rescuing dogs from overseas is increasing in popularity but has associated risks. This study is the first to investigate the reasons why people bring rescue dogs into the UK from overseas, the importation process, and potential welfare problems associated with this practice.

METHODS

An online questionnaire was advertised on social media in 2017 and received 3080 responses.

RESULTS

Participants primarily chose to adopt from abroad based on a desire for a particular dog they had seen advertised and on concern for its situation. However, some were motivated by previously having been refused dogs from UK rescues. Adopters reported that the EU Pet Travel Scheme was used to import 89 per cent of dogs, with only 1.2 per cent reportedly under the more stringent (and correct) Balai Directive. 14.8 per cent (79/533) of dogs reportedly tested for Leishmania infantum had positive results. Although sometimes severe, the prevalence of behavioural problems appeared comparable to that of other rescue dogs.

CONCLUSION

It is important that vets consider testing for exotic diseases, and the provision of behavioural support, when seeing imported patients. Our findings emphasise the importance of clear guidelines on travel laws, and stricter checks on animals imported as rescues, to ensure protection against the importation of diseases that pose a risk to animal and human health in the UK.

Rescue high frequency ventilation for congenital diaphragmatic hernia

INTRODUCTION

High frequency jet (HFJV) and oscillatory (HFOV) ventilation were used to rescue newborns with congenital diaphragmatic hernia (CDH), who failed conventional mechanical ventilation (CV). Changes in ventilator settings and pulmonary gas exchange were evaluated following transition to high frequency ventilation (HFV).

METHODS

Records of patients with CDH rescued with HFV prior to surgical intervention between 2006 and 2015 were reviewed. Mean airway pressure (Pāw) and arterial blood gases during CV and those obtained within the first hour of HFV were compared. A composite repeated measure analysis was performed to evaluate longitudinal and intergroup variances.

RESULTS

Twenty-seven patients were rescued from CV, 16 by HFJV and 11 by HFOV. The two groups had similar gestational ages and birth weights. Prior to HFV, both groups had similar Pāw, PaCO2, FiO2 and PaO2. HFV was associated with a significant improvement in ventilation, and the rate of decrease of PaCO2 was no different between groups. There was a significantly higher increase in Pāw increase with HFOV compared to HFJV.

CONCLUSIONS

In newborns with CDH rescued with HFV, ventilation improved but Pāw was significantly lower in patients supported with HFJV compared to HFOV.

Mortality in Via Ferrata Emergencies in Austria from 2008 to 2018

Although the European Alps now have more than 1000 via ferratas, limited data exist on the actual incidence of fatal events in via ferratas and their causes. This retrospective study analysed data from a registry maintained by the Austrian Alpine Safety Board (n = 161,855, per 11 September 2019). Over a 10-year period from 1 November 2008 to 31 October 2018, all persons involved in a via ferrata-related emergency were included (n = 1684), of which 64% were male. Most emergencies were caused by blockage due to exhaustion and/or misjudgement of the climber’s own abilities. Consequently, more than half of all victims were evacuated uninjured. Only 62 (3.7%) via ferrata-related deaths occurred. Falling while climbing unsecured was the most common cause of death, and males had a 2.5-fold higher risk of dying in a via ferrata accident. The mortality rate was highest in technically easy-to-climb sections (Grade A, 13.2%/B, 4.9%), whereas the need to be rescued uninjured was highest in difficult routes (Grade D, 59.9%/E, 62.7%). Although accidents in via ferratas are common and require significant rescue resources, fatal accidents are rare. The correct use of appropriate equipment in technically easy-to-climb routes can prevent the majority of these fatalities.

Overexpression of mitochondrial histidyl-tRNA synthetase restores mitochondrial dysfunction caused by a deafness-associated tRNAHis mutation

The deafness-associated m.12201T>C mutation affects the A5-U68 base-pairing within the acceptor stem of mitochondrial tRNA^His The primary defect in this mutation is an alteration in tRNA^His aminoacylation. Here, we further investigate the molecular mechanism of the deafness-associated tRNA^His 12201T>C mutation and test whether the overexpression of the human mitochondrial histidyl-tRNA synthetase gene (HARS2) in cytoplasmic hybrid (cybrid) cells carrying the m.12201T>C mutation reverses mitochondrial dysfunctions. Using molecular dynamics simulations, we demonstrate that the m.12201T>C mutation perturbs the tRNA^His structure and function, supported by decreased melting temperature, conformational changes, and instability of mutated tRNA. We show that the m.12201T>C mutation-induced alteration of aminoacylation tRNA^His causes mitochondrial translational defects and respiratory deficiency. We found that the transfer of HARS2 into the cybrids carrying the m.12201T>C mutation raises the levels of aminoacylated tRNA^His from 56.3 to 75.0% but does not change the aminoacylation of other tRNAs. Strikingly, HARS2 overexpression increased the steady-state levels of tRNA^His and of noncognate tRNAs, including tRNA^Ala, tRNA^Gln, tRNA^Glu, tRNA^Leu(UUR), tRNA^Lys, and tRNA^Met, in cells bearing the m.12201T>C mutation. This improved tRNA metabolism elevated the efficiency of mitochondrial translation, activities of oxidative phosphorylation complexes, and respiration capacity. Furthermore, HARS2 overexpression markedly increased mitochondrial ATP levels and membrane potential and reduced production of reactive oxygen species in cells carrying the m.12201T>C mutation. These results indicate that HARS2 overexpression corrects the mitochondrial dysfunction caused by the tRNA^His mutation. These findings provide critical insights into the pathophysiology of mitochondrial disease and represent a step toward improved therapeutic interventions for mitochondrial disorders.

Evaluation of a Simplified Loops System for Emergency Rescue Lifting of the Stranded or Recumbent Horse

Simple Summary

Horses, once stranded or recumbent, can hurt themselves and endanger the personnel trying to rescue them. Successful rescuing of these horses often requires emergency lifting. The objective of this study is to describe a new sling system for short-term lifting of horses. This simple system, called here the Loop Vertical Lift System, or Loops System, utilizes commercially available, and reasonably priced equipment that when used correctly may save lives of stranded horses needing emergency rescue and short-term lifting.

Abstract

Stranded and recumbent equids often require emergency rescue, and a successful rescue often requires vertical lifting of the animal. Currently, the devices used for vertical lifting of equids are not readily available at an incident or urgent situation. The current study describes and evaluates the use of a simple lift device utilizing commercially available, and reasonably priced, equipment. The system, referred to as the Loop Vertical Lift System or Loops System, is basically composed of four round slings placed in such a way that utilizes the skeletal system for support. The study demonstrates the lifting of six standing, sedated adult horses for 3 min without adverse effects. In conclusion, this novel lift system is an affordable, practical and quick alternative to rescue a stranded or recumbent horse that requires a brief vertical lift of the animal. In contrast, for longer-term lifting and support, other devices such as the UC Davis Large Animal Lift, the Anderson Sling Support Device, or the Animal Rescue and Transport Sling (ARTS) should be used as deemed appropriate.

Safety and efficacy of midazolam nasal spray in the outpatient treatment of patients with seizure clusters: An open-label extension trial

OBJECTIVE

To evaluate safety- and seizure-related outcomes with repeated intermittent use of a novel formulation of midazolam administered as a single-dose nasal spray (MDZ-NS) in the outpatient treatment of patients experiencing seizure clusters (SCs).

METHODS

In this open-label extension trial (ClinicalTrials.gov NCT01529034), patients aged ≥12 years and on a stable regimen of antiepileptic drugs who completed the original phase III, randomized controlled trial were enrolled. Caregivers administered MDZ-NS 5 mg when patients experienced SCs; a second dose could be given if seizures did not terminate within 10 minutes or recurred within 10 minutes-6 hours. Patients were monitored for treatment-emergent adverse events (TEAEs) throughout, and the main seizure-related outcome was treatment success, defined as seizure termination within 10 minutes and no recurrence 10 minutes-6 hours after drug administration.

RESULTS

Of 175 patients enrolled, 161 (92.0%) received ≥1 MDZ-NS dose, for a total of 1998 SC episodes. Median time spent by patients in the trial was 16.8 months (range = 1-55.7 months). TEAEs were experienced by 40.4% of patients within 2 days of drug administration and 57.1% overall. TEAEs reported by most patients (within 2 days and overall) were nasal discomfort (12.4%) and somnolence (9.3%). One patient each discontinued due to treatment-related nasal discomfort and somnolence. There were no patients with treatment-related respiratory depression, and none with TEAEs indicative of drug abuse or dependence. Treatment success criteria were met in 55% (1108/1998) of SC episodes after administration of a single 5-mg dose and in 80.2% (617/769) with the second dose. Treatment success was consistent over treated episode number.

SIGNIFICANCE

Repeated, intermittent, acute treatment of patients experiencing SCs with MDZ-NS in the outpatient setting was well tolerated over an extended period, with maintenance of efficacy suggesting lack of development of tolerance.

The impact of cerclage in twin pregnancies on preterm birth rate before 32 weeks

PURPOSE

To evaluate whether cerclage in twins reduces the rate of spontaneous preterm birth <32 weeks when compared to expectant management.

METHODS

This is a retrospective cohort study of twin pregnancies with the following indications for cerclage from two institutions: history of prior preterm birth, ultrasound-identified short cervix ≤2.5 cm, and cervical dilation ≥1.0 cm. The "cerclage" cohort received a cerclage from a single provider at a single institution from 2003-2016. The "no cerclage" group included all patients with similar indications that were expectantly managed from 2010-2015, at a second institution where cerclages are routinely not performed in twin pregnancies. The primary outcome was the rate of spontaneous preterm birth at <32 weeks. Secondary outcomes were the rates of spontaneous and overall (including medically indicated) preterm births at <32 weeks, < 34 weeks, and <36 weeks, chorioamnionitis, birth weight, and neonatal mortality within 30 days of life. We also performed a planned subgroup analysis stratified by cerclage indication.

RESULTS

In all, 135 women were included in two cohorts: cerclage (n = 96) or no cerclage (n = 39). The rates of spontaneous preterm birth <32 weeks were 10.4% (n = 10) with cerclage versus 28.2% (n = 11) without cerclage (OR 0.23, CI 0.08-0.70, p = .017). After adjusting for cerclage indication, clinical history, age, chorionicity, insurance type, race, BMI, in-vitro fertilization, and multifetal reduction, there remained a significant reduction in the cerclage group of spontaneous preterm birth <32 weeks (adjusted odds ratio (aOR) 0.24, CI 0.06-0.90, p = .035), spontaneous preterm birth <36 weeks (aOR 0.34, CI 0.04-0.81, p = .013) as well as in overall preterm birth <32 weeks (aOR 0.31, CI 0.1-0.86, p = .018), and overall preterm birth <36 weeks (aOR 0.37, CI 0.10-0.84, p = .030). When stratified by short cervix or cervical dilation in the cerclage versus no cerclage groups, there was a significant decrease in spontaneous preterm birth <32 weeks in the cerclage group with cervical dilation (11.1 versus 41.2%, p = .01) but not in the cerclage group with short cervix only, even for cervical length <1.5 cm. Pregnancy latency was 91 days in the cerclage group versus 57 days in the no cerclage group (p = .001), with a median gestational age at delivery of 35 versus 32 weeks (p = .002). There was no increase in chorioamnionitis in the cerclage group. Furthermore, there was a significant increase in birth weight (median 2278 versus 1665 g, p < .001) and decrease in perinatal death <30 days (1.6 versus 12.9%, p = .001).

CONCLUSIONS

Cerclage in twin pregnancies significantly decreased the rate of spontaneous preterm birth <32 weeks compared to expectant management. However, when stratified by cerclage indication, this decrease in primary outcome only remained significant in the group with cervical dilation.

Advances and Challenges in Pharmaceutical Therapies to Prevent and Repair Cochlear Injuries From Noise

Noise induces a broad spectrum of pathological injuries to the cochlea, reflecting both mechanical damage to the delicate architecture of the structures of the organ of Corti and metabolic damage within the organ of Corti and lateral wall tissues. Unlike ototoxic medications, the blood-labyrinth barrier does not offer protection against noise injury. The blood-labyrinth barrier is a target of noise injury, and can be weakened as part of the metabolic pathologies in the cochlea. However, it also offers a potential for therapeutic intervention with oto-protective compounds. Because the blood-labyrinth barrier is weakened by noise, penetration of blood-borne oto-protective compounds could be higher. However, systemic dosing for cochlear protection from noise offers other significant challenges. An alternative option to systemic dosing is local administration to the cochlea through the round window membrane using a variety of drug delivery techniques. The review will discuss noise-induced cochlear pathology, including alterations to the blood-labyrinth barrier, and then transition into discussing approaches for delivery of oto-protective compounds to reduce cochlear injury from noise.

Safety and efficacy of midazolam nasal spray in the outpatient treatment of patients with seizure clusters-a randomized, double-blind, placebo-controlled trial

Objective

To evaluate the safety and efficacy of a novel formulation of midazolam administered as a single‐dose nasal spray (MDZ–NS) in the outpatient treatment of patients experiencing seizure clusters (SCs).

Methods

This was a phase III, randomized, double‐blind, placebo‐controlled trial (ClinicalTrials.gov NCT01390220) with patients age ≥12 years on a stable regimen of antiepileptic drugs. Following an in‐clinic test dose phase (TDP), patients entered an outpatient comparative phase (CP) and were randomized (2:1) to receive double‐blind MDZ–NS 5 mg or placebo nasal spray, administered by caregivers when they experienced an SC. The primary efficacy end point was treatment success (seizure termination within 10 minutes and no recurrence 10 minutes to 6 hours after trial drug administration). Secondary efficacy end points were proportion of patients with seizure recurrence 10 minutes to 4 hours, and time‐to‐next seizure >10 minutes after double‐blind drug administration. Safety was monitored throughout.

Results

Of 292 patients administered a test dose, 262 patients were randomized, and 201 received double‐blind treatment for an SC (n = 134 MDZ–NS, n = 67 placebo, modified intent‐to‐treat population). A significantly greater proportion of MDZ–NS‐ than placebo‐treated patients achieved treatment success (53.7% vs 34.4%; P = 0.0109). Significantly, fewer MDZ–NS‐ than placebo‐treated patients experienced seizure recurrence (38.1% vs 59.7%; P = 0.0043). Time‐to‐next seizure analysis showed early separation (within 30 minutes) between MDZ–NS and placebo that was maintained throughout the 24‐hour observation period (21% difference at 24 hours; P = 0.0124). Sixteen patients (5.5%) discontinued because of a treatment‐emergent adverse event (TEAE) during the TDP and none during the CP. During the CP, 27.6% and 22.4% of patients in the MDZ–NS and placebo groups, respectively, experienced ≥1 TEAE.

Significance

MDZ–NS was superior to placebo in providing rapid, sustained seizure control when administered to patients experiencing an SC in the outpatient setting and was associated with a favorable safety profile.