Tocilizumab in COVID-19: a meta-analysis, trial sequential analysis, and meta-regression of randomized-controlled trials

PURPOSE: Interleukin-6 (IL-6) levels discriminate between patients with mild and severe COVID-19, making IL-6 inhibition an attractive therapeutic strategy. We conducted a systematic review, meta-analysis, trial sequential analysis (TSA), and meta-regression of randomized-controlled trials to ascertain the benefit of IL-6 blockade with tocilizumab for COVID-19. METHODS: We included randomized-controlled trials (RCTs) allocating patients with COVID-19 to tocilizumab. Our control group included standard care or placebo. Trials co-administering other pharmacological interventions for COVID-19 were not excluded. Primary outcome was 28–30 day mortality. Secondary outcomes included progression-to-severe disease defined as need for mechanical ventilation, intensive-care unit (ICU) admission, or a composite. RESULTS: We identified 10 RCTs using tocilizumab, 9 of which reported primary outcome data (mortality), recruiting 6493 patients with 3358 (52.2%) allocated to tocilizumab. Tocilizumab may be associated with an improvement in mortality (24.4% vs. 29.0%; OR 0.87 [0.74–1.01]; p = 0.07; I2 = 10%; TSA adjusted CI 0.66–1.14). Meta-regression suggested a relationship between treatment effect and mortality risk, with benefit at higher levels of risk (logOR vs %risk beta = −0.018 [−0.037 to −0.002]; p = 0.07). Tocilizumab did reduce the need for mechanical ventilation and was associated with a benefit in the composite secondary outcome but did not reduce ICU admission. CONCLUSIONS: For hospitalized COVID-19 patients, there is some evidence that tocilizumab use may be associated with a short-term mortality benefit, but further high-quality data are required. Its benefits may also lie in reducing the need for mechanical ventilation

Convalescent plasma for COVID-19: a meta-analysis, trial sequential analysis, and meta-regression

Background: SARS-CoV-2-specific antibodies, particularly those preventing interaction between the viral spike receptor-binding domain and the host angiotensin-converting enzyme 2 receptor, may prevent viral entry into host cells and disease progression. / Objective: We performed a systematic review, meta-analysis, trials sequential analysis (TSA) and meta-regression of randomized control trials (RCTs) to evaluate the benefit of convalescent plasma for COVID-19. The primary outcome was 28-30-day mortality. Secondary outcomes included need for mechanical ventilation and intensive care (ICU) admission. / Data sources: PubMed, Embase, MedRxiv, and the Cochrane library on 2nd July 2021. / Results: Seventeen RCTs were identified recruiting 15,587 patients with 8027 (51.5%) allocated to receive convalescent plasma. Convalescent plasma use was not associated with a mortality benefit (24.7% vs. 25.5%; OR 0.94 (0.85 – 1.04); p = 0.23; I2 = 4%; TSA adjusted CI 0.84 – 1.05), or reduction in need for mechanical ventilation (15.7% vs. 15.4%; OR 1.01 [0.92 – 1.11]; p = 0.82; I2 = 0%; TSA adjusted CI 0.91 – 1.13), or ICU admission (22.4% vs. 16.7%; OR 0.80 (0.21 – 3.09); p = 0.75; I2 = 63%; TSA adjusted CI 0.0 – 196.05). Meta-regression did not reveal any association with titre of convalescent plasma, timing of administration, nor risk of death and treatment effect (p>0.05). Risk of bias was high in most studies. / Conclusions: In patients with COVID-19, there was no clear mortality benefit associated with convalescent plasma. In patients with mild disease, convalescent plasma did not prevent either the need for mechanical ventilation or ICU admission. PROSPERO registration CRD42021234201

Biological sex is associated with heterogeneous responses to IL-6 receptor inhibitor treatment in COVID-19—A retrospective cohort study

COVID-19 is associated with higher inflammatory markers, illness severity and mortality in males compared to females. Differences in immune responses to COVID-19 may underpin sex- specific outcome differences. We hypothesised that anti-IL-6 receptor monoclonal antibodies are associated with heterogenous treatment effects between male and female patients. We conducted a retrospective cohort study assessing the interaction between biological sex and anti-IL-6 receptor antibody treatment with respect to hospital mortality or progression of respiratory failure. We used a Cox proportional hazards regression model to adjust for age, ethnicity, steroid use, baseline C-reactive protein, and COVID-19 variant. We included 1274 patients, of which 58% were male and 15% received anti-IL-6 receptor antibodies. There was a significant interaction between sex and anti-IL-6 receptor antibody use on progression to respiratory failure or death (p = 0.05). For patients who did not receive anti-IL-6 receptor antibodies, the risk of death was slightly higher in males (HR = 1.13 (0.72–1.79)), whereas in patients who did receive anti-IL-6 receptor antibodies, the risk was lower in males (HR = 0.65 (0.32–1.33)). There was a heterogenous treatment effect with anti-IL-6 receptor antibodies between males and females; with anti-IL-6 receptor antibody use having a greater benefit in preventing progression to respiratory failure or death in males (p = 0.05)

Agile user stories enriched with usability

Usability is a critical quality factor. Therefore, like traditional software teams, agile teams have to address usability to properly catch their users experience. There exists an interesting debate in the agile and usability communities about how to achieve this integration. Our aim is to contribute to this debate by discussing the incorporation of particular usability recommendations into user stories, one of the most popular artifacts for communicating agile requirements. In this paper, we explore the implications of usability for both the structure of and the process for defining user stories. We discuss what changes the incorporation of particular usability issues may introduce in a user story. Although our findings require more empirical validation, we think that they are a good starting point for further research on this line

Measuring Interaction Design before Building the System: a Model-Based Approach

Early prototyping of user interfaces is an established good practice in interactive system development. However, prototypes cover only some usage scenarios, and questions dealing with number of required steps, possible interaction paths or impact of possible user errors can be answered only for the specific scenarios and only after tedious manual inspection. We present a tool (MIGTool) that transforms models of the behavior of a user interface into a graph, upon which usage scenarios can be easily specified, and used by MIGTool to compute possible interaction paths. Metrics based on possible paths, with or without user navigation errors, can then be computed. For example, when analyzing four mail applications, we show that Gmail has 3 times more shortest routes, has twice more routes that include a single user error, has routes with 13\ufewer steps, but has also optimal routes with the smallest probability to be chosen. Without MIGTool, this kind of analysis could only be done after building some prototype of the system, and then only for specific scenarios by manually tracing user actions and relative changes to the screens. With MIGTool the exploration of suitability of a design with respect to different scenarios, or comparison of different design alternatives against a single scenario, can be done with just a partial specification of the user interface behavior. This is made possible by the ability to associate scenarios steps to required user actions as defined in the model, by an efficient strategy to identify complete execution traces that users can follow, and by computing a range of diverse metrics on these results

Intravenous Thrombolysis Before Mechanical Thrombectomy for Acute Ischemic Stroke: A Meta‐Analysis

Background: Whether intravenous thrombolysis before mechanical thrombectomy provides additional benefit for functional outcome in acute ischemic stroke remains uncertain. We performed a meta‐analysis to compare the outcomes of direct mechanical thrombectomy (dMT) to mechanical thrombectomy with bridging using intravenous thrombolysis (bridging therapy [BT]) in patients with acute ischemic stroke. / Methods and Results: We performed a literature search in the PubMed, Excerpta Medica database, and Cochrane Central Register of Controlled Trials from January 1, 2003, to April 26, 2021. We included randomized clinical trials and observational studies that reported the 90‐day functional outcome in patients with acute ischemic stroke undergoing dMT compared with BT. The 12 included studies (3 randomized controlled trials and 9 observational studies) yielded 3924 participants (mean age, 68.0 years [SD, 13.1 years]; women, 44.2%; 1887 participants who received dMT and 2037 participants who received BT). A meta‐analysis of randomized controlled trial and observational data revealed similar 90‐day functional independence (odds ratio [OR], 1.04; 95% CI, 0.90–1.19), mortality (OR, 1.03; 95% CI, 0.78–1.36), and successful recanalization (OR, 0.93; 95% CI, 0.76–1.14) for patients treated with dMT or BT. Compared with those in the BT group, patients in the dMT group were less likely to experience symptomatic intracranial hemorrhage (OR, 0.68; 95% CI, 0.51–0.91; P=0.008) or any intracranial hemorrhage (OR, 0.71; 95% CI, 0.61–0.84; P<0.001). / Conclusions: In this meta‐analysis of patients with acute ischemic stroke, we found no significant differences in 90‐day functional outcome or mortality between dMT and BT, but a lower rate of symptomatic intracranial hemorrhage for dMT. These findings support the use of dMT without intravenous thrombolysis bridging therapy. / Registration: URL: https://www.crd.york.ac.uk/prospero/; Unique identifier: 42021234664

Proteogenomic analysis of mycobacterium smegmatis using high resolution mass spectrometry

Biochemical evidence is vital for accurate genome annotation. The integration of experimental data collected at the proteome level using high resolution mass spectrometry allows for improvements in genome annotation by providing evidence for novel gene models, while validating or modifying others. Here, we report the results of a proteogenomic analysis of a reference strain of Mycobacterium smegmatis (mc2155), a fast growing model organism for the pathogenic Mycobacterium tuberculosis—the causative agent for Tuberculosis. By integrating high throughput LC/MS/MS proteomic data with genomic six frame translation and ab initio gene prediction databases, a total of 2887 ORFs were identified, including 2810 ORFs annotated to a Reference protein, and 63 ORFs not previously annotated to a Reference protein. Further, the translational start site (TSS) was validated for 558 Reference proteome gene models, while upstream translational evidence was identified for 81. In addition, N-terminus derived peptide identifications allowed for downstream TSS modification of a further 24 gene models. We validated the existence of six previously described interrupted coding sequences at the peptide level, and provide evidence for four novel frameshift positions. Analysis of peptide posterior error probability (PEP) scores indicates high-confidence novel peptide identifications and shows that the genome of M. smegmatis mc2155 is not yet fully annotated. Data are available via ProteomeXchange with identifier PXD003500

Future COVID-19 Booster Vaccine Refusal in Healthcare Workers after a Massive Breakthrough Infection Wave, a Nationwide Survey-Based Study

Background: An unprecedented coronavirus disease 2019 (COVID-19) wave occurred in China between December 2022 and January 2023, challenging the efficacy of the primary series of COVID-19 vaccines. The attitudes toward future COVID-19 booster vaccines (CBV) after the massive breakthrough infection among healthcare workers remain unknown. This study aimed to explore the prevalence and determinants of future CBV refusal after the unprecedented COVID-19 wave among healthcare workers. Methods: Between 9 and 19 February 2023, a cross-sectional nationwide online survey was conducted using a self-administered questionnaire vaccine among healthcare workers in China. Sociodemographics, profession, presence of chronic medical conditions, previous COVID-19 infection, attitudes towards future CBV, and reasons for future CBV refusal were collected. We estimated odds ratio [OR] with 95% confidence interval [CI] using a multivariable logistic regression model to explore the factors associated with future CBV refusal. Results: Among the 1618 participants who completed the survey, 1511 respondents with two or more doses of COVID-19 vaccines were analyzed. A total of 648 (41.8%) of respondents were unwilling to receive a future CBV. Multivariable logistic regression analysis revealed the association of CBV refusal with profession (vs. other staff, physician-adjusted OR 1.17, 95%CI 0.79–1.72, nurse-adjusted OR 1.88, 95%CI 1.24−2.85, p = 0.008), history of allergy (adjusted OR 1.72, 95%CI 1.05–2.83, p = 0.032), a lower self-perceived risk of future COVID-19 infection (p < 0.001), and a lower belief in CBV effectiveness (p = 0.014), safety (p < 0.001), and necessities for healthcare workers and the public (p < 0.001, respectively). Conclusions: Our findings highlight that a considerable proportion of healthcare workers were against a future booster dose after an unprecedented COVID-19 wave. Self-perception of future COVID-19 risk, and potential harm or doubtful efficacy of vaccines are the main determinants. Our findings may help public health authorities to establish future COVID-19 vaccination programs

An Improved Implementation and Abstract Interface for Hybrid

Hybrid is a formal theory implemented in Isabelle/HOL that provides an interface for representing and reasoning about object languages using higher-order abstract syntax (HOAS). This interface is built around an HOAS variable-binding operator that is constructed definitionally from a de Bruijn index representation. In this paper we make a variety of improvements to Hybrid, culminating in an abstract interface that on one hand makes Hybrid a more mathematically satisfactory theory, and on the other hand has important practical benefits. We start with a modification of Hybrid's type of terms that better hides its implementation in terms of de Bruijn indices, by excluding at the type level terms with dangling indices. We present an improved set of definitions, and a series of new lemmas that provide a complete characterization of Hybrid's primitives in terms of properties stated at the HOAS level. Benefits of this new package include a new proof of adequacy and improvements to reasoning about object logics. Such proofs are carried out at the higher level with no involvement of the lower level de Bruijn syntax.Comment: In Proceedings LFMTP 2011, arXiv:1110.668

Efficacy of Repeat Selective Laser Trabeculoplasty in Medication-Naïve Open Angle Glaucoma and Ocular Hypertension during the LiGHT Trial

PURPOSE: To determine the efficacy of repeat selective laser trabeculoplasty (SLT) in medication-naïve open angle glaucoma (OAG) and ocular hypertensive (OHT) patients requiring repeat treatment for early to medium-term failure during the Laser in Glaucoma and Ocular Hypertension (LiGHT) trial. // DESIGN: Post-hoc analysis of SLT treatment arm of a multicentre prospective randomised-controlled-trial. // PARTICIPANTS: Treatment-naïve OAG or OHT requiring repeat 360-degree SLT within 18 months. Re-treatment was triggered by pre-defined IOP and disease-progression criteria (using objective individualised target IOPs) // METHODS: After SLT at baseline, patients were followed for a minimum of 18 months after second (‘repeat’) SLT. A mixed model analysis was performed with the eye as the unit of analysis, with crossed random-effects to adjust for correlation between fellow eyes and repeated measures within eyes. Kaplan-Meier curves plot the duration of effect. // OUTCOME MEASURES: Initial (‘early’) IOP lowering at 2-months and duration of effect following initial and Repeat SLT. // RESULTS: 115 eyes of 90 patients received Repeat SLT during first 18 months of the trial. Pre-treatment IOP prior to Initial SLT was significantly higher than that prior to pre-retreatment IOP of Repeat SLT (mean difference: 3.4, 95% confidence interval (CI) 2.6 to 4.3, mmHg; p<0.001). Absolute IOP reduction at 2-months was greater following Initial, compared to Repeat, SLT (mean difference: 1.0, 95% CI 0.2 to 1.8, mmHg; p=0.02). Adjusted absolute IOP reduction at 2-months (adjusting for IOP prior to initial or repeat laser) was greater following Repeat SLT (adjusted mean difference: -1.1, 95% CI -1.7 to -0.5, mmHg; p=0.001). 34 eyes were ‘early failures’ (retreated 2-months after Initial SLT) vs 81 ‘later failures’ (retreatment beyond 2-months following Initial SLT). No significant difference in early absolute IOP reduction at 2-months following Repeat SLT was noted between ‘early’ vs ‘later’ failures’ (mean difference: 0.3, 95% CI, -1.1 to 1.8,mmHg; p=0.655). Repeat SLT maintained drop-free IOP control in 67% of 115 eyes at 18 months, with no clinically-relevant adverse events. // CONCLUSION: These exploratory analyses demonstrate Repeat SLT can maintain IOP at or below Target IOP in medication-naive OAG and OHT eyes requiring retreatment with atleast an equivalent duration of effect to initial laser