Prognostic Value of Weekly Delta-Radiomics during MR-Linac Radiotherapy of Glioblastoma

PURPOSE/OBJECTIVE(S)

MRI after chemoradiotherapy (chemoRT) shows areas of presumed tumor growth in ≤ 50% of glioblastoma (GBM) patients, which can be true progression (TP) - tumor growth with poor treatment response, or pseudoprogression (PP) - edema and tumor necrosis with favorable treatment response. Patients with TP have median overall survival (OS) of only 7 months, while patients with PP have median OS of 36 months. However, on imaging, TP and PP are usually not discernible during treatment, making it difficult to adapt radiation for poor responders. The purpose of this study was to investigate the prognostic value of delta radiomic features from MR-Linac for GBM.

MATERIALS/METHODS

Using an IRB-approved prospective cohort of GBM patients undergoing 30 fractions of chemoRT to 60 Gy on a 0.35T MR-Linac, 2 regions of interest (ROI) were contoured on daily T2-weighted treatment set-up scans: 1) tumor/edema (lesion) and 2) post-surgical resection cavity (RC). The lesion ROI were used to calculate texture features: second order radiomics features based on the gray-level co-occurrence matrix (GLCM), gray-level size zone matrix (GLSZM), gray-level run length matrix (GLRLM), and neighborhood gray-tone difference matrix (NGTDM). Each of these describe the probability of spatial relationships of gray levels occurring within the ROI. Features from fraction 1 (pre-radiation) were subtracted from fractions 5, 10, 15, 25, and 30 to create delta features at 5 timepoints (D5-D30). Patient response was retrospectively defined as no progression (NP), TP, or PP. Supervised machine learning was utilized using a 500-tree random forest (RF) classification model with TP or PP as the outcome. Variable importance analysis was conducted by calculating the out-of-bag errors with multiple bootstrapped data sets. The most prognostic features were selected using the RF importance scores.

RESULTS

Thirty-six patients were screened for inclusion: 9 were excluded due to no T2 lesion (RC ROI only). Of the remaining 27 patients: 10 had NP, 11 had TP, and 6 had PP. Thirty-nine texture features, plus lesion volume and mean lesion intensity (for a total of 41 variables per time point) were calculated and included in the model. Of the 10 most prognostic features, 6 were from D10, suggesting that prognostic changes in the underlying lesion microenvironment are occurring within the first 10 fractions of treatment. The model selected GLSZM high gray-level zone emphasis (HGZE) D10, IBSI code 5GN9, as the most prognostic feature. The receiver operator characteristic (ROC) area under the curve (AUC) for GLSZM HGZE D10 was 0.94 (95% CI = 0.81-1.00).

CONCLUSION

Delta radiomic features extracted from MR-Linac imaging may predict between PP and TP in GBM patients during treatment, which is earlier than current methods. This could allow physicians to adapt/intensify treatment in real time for poorly responding patients. Future directions include analysis with a larger patient cohort and with additional MRI contrasts (MR-Linac multiparametric MRI).

Quality of life with first-line pembrolizumab for PD-L1-positive advanced gastric/gastroesophageal junction adenocarcinoma: results from the randomised phase III KEYNOTE-062 study

BACKGROUND

In the randomised phase III KEYNOTE-062 study, pembrolizumab was non-inferior to chemotherapy for overall survival in patients with programmed death-ligand 1 (PD-L1)-positive [combined positive score (CPS) ≥1] advanced gastric/gastroesophageal junction (GEJ) cancer. We present findings of prespecified health-related quality-of-life (HRQOL) analyses for pembrolizumab versus chemotherapy in this population.

MATERIALS AND METHODS

HRQOL, a secondary endpoint, was measured in patients who received ≥1 dose of study treatment and completed ≥1 HRQOL questionnaire [European Organisation for the Research and Treatment of Cancer (EORTC) 30-question quality-of-life (QLQ-C30), EORTC 22-question quality-of-life gastric-cancer-specific module (QLQ-STO22)]. Least squares mean (LSM) change (baseline to week 18) in global health status/quality of life (GHS/QOL; EORTC QLQ-C30) and time to deterioration (TTD) in GHS/QOL, nausea/vomiting and appetite loss scores (EORTC QLQ-C30) and abdominal pain/discomfort scores (EORTC QLQ-STO22) were evaluated.

RESULTS

The HRQOL population comprised 495 patients with CPS ≥1 (pembrolizumab, 252; chemotherapy, 243). Compliance rates at week 18 were similar for pembrolizumab and chemotherapy (EORTC QLQ-C30, 87.9% and 81.9%; EORTC QLQ-STO22, 87.9% and 81.3%, respectively). There was no between-arm difference in LSM score change in GHS/QOL [-0.16; 95% confidence interval (CI) -5.01 to 4.69; P = 0.948]. The LSM score change for most subscales showed comparable worsening in both arms. TTD for GHS/QOL [hazard ratio (HR), 0.96; 95% CI, 0.67-1.38; P = 0.826], appetite loss (HR, 0.83; 95% CI, 0.58-1.20; P = 0.314) and pain (HR, 1.22; 95% CI, 0.78-1.91; P = 0.381) were similar between arms. Longer TTD was observed for pembrolizumab versus chemotherapy for nausea/vomiting (HR, 0.61; 95% CI, 0.44-0.85; P = 0.003).

CONCLUSIONS

HRQOL was maintained with first-line treatment with pembrolizumab in patients with PD-L1-positive advanced gastric/GEJ cancer and was similar between pembrolizumab and chemotherapy in this population.

Protein-conformational diseases in childhood: Naturally-occurring hIAPP amyloid-oligomers and early β-cell damage in obesity and diabetes

BACKGROUND AND AIMS

This is the first time that obesity and diabetes mellitus (DM) as protein conformational diseases (PCD) are reported in children and they are typically diagnosed too late, when β-cell damage is evident. Here we wanted to investigate the level of naturally-ocurring or real (not synthetic) oligomeric aggregates of the human islet amyloid polypeptide (hIAPP) that we called RIAO in sera of pediatric patients with obesity and diabetes. We aimed to reduce the gap between basic biomedical research, clinical practice-health decision making and to explore whether RIAO work as a potential biomarker of early β-cell damage.

MATERIALS AND METHODS

We performed a multicentric collaborative, cross-sectional, analytical, ambispective and blinded study; the RIAO from pretreated samples (PTS) of sera of 146 pediatric patients with obesity or DM and 16 healthy children, were isolated, measured by sound indirect ELISA with novel anti-hIAPP cytotoxic oligomers polyclonal antibody (MEX1). We carried out morphological and functional studied and cluster-clinical data driven analysis.

RESULTS

We demonstrated by western blot, Transmission Electron Microscopy and cell viability experiments that RIAO circulate in the blood and can be measured by ELISA; are elevated in serum of childhood obesity and diabetes; are neurotoxics and works as biomarkers of early β-cell failure. We explored the range of evidence-based medicine clusters that included the RIAO level, which allowed us to classify and stratify the obesity patients with high cardiometabolic risk.

CONCLUSIONS

RIAO level increases as the number of complications rises; RIAOs > 3.35 μg/ml is a predictor of changes in the current indicators of β-cell damage. We proposed a novel physio-pathological pathway and shows that PCD affect not only elderly patients but also children. Here we reduced the gap between basic biomedical research, clinical practice and health decision making.

Double-layer carbon nanocapsules with radioiodine content and its interaction with calcium, phosphorus, and strontium

First principles calculations have been performed for C₆₀@C₁₈₀ carbon double-layer endofullerenes with up to: three diatomic radioiodine molecules (¹³¹I₂), two potassium radio-iodide (K¹³¹I), and three sodium radio-iodide (Na¹³¹I) inside. The plane-wave pseudopotential (PP) method within the general gradient approximation (GGA) in the framework of the density functional theory (DFT) and time-dependent DFT (TD-DFT) was used to perform geometric optimizations (GOs) and molecular dynamics (MD) at 310 K and atmospheric pressure. We found that the double-layer carbon nanocapsules formed by two concentric fullerenes (C₁₈₀ surrounding C₆₀) are very stable and may contain a radiodosis, without altering their configuration; that is, the 3(¹³¹I₂)@C₆₀@C₁₈₀, 2(K¹³¹I)@C₆₀@C₁₈₀, and 3(Na¹³¹I)@C₆₀@C₁₈₀ systems constitute stable nanocapsules. We analyzed the interaction of double-layer endofullerene with radioactive content with some calcium, phosphorus, and strontium atoms, [n(X¹³¹I)@C₆₀@C₁₈₀ + mY], for X = I, K, Na; Y = Ca, P, Sr; n = 1, 2, 3; m = 1, …, 20. Our calculations show that up to m = 20 calcium atoms can easily be physisorbed by the outer surface of the double-layer endofullerene, maintaining their integrity and shielding the radiodosis of any interaction that can proceed from the outside. It is thus concluded that these double-layer endofullerenes can be functionalized as vectors to deliver radiodosis with structural advantages over the single layer systems; as they are more robust, stable, and possess a larger surface to functionalize with some atoms serving as molecular recognizers. Graphical abstract Double-layer carbon nanocapsules with radioiodine content and its interaction with calcium, phosphorus and strontium.

Interactions of calcium with the external surfaces of fullerenes and endofullerenes doped with radioactive sodium iodide

We report first-principles calculations carried out to analyze the adsorption of calcium on the outer surface of the fullerene C₆₀, yielding [C₆₀ + mCa]. Geometric optimization (GO) and molecular dynamics (MD) simulation were performed using the plane-wave pseudopotential method within the framework of density functional theory (DFT) and time-dependent DFT (TD-DFT) to investigate the configurations, the associated energies in the ground state, and the stabilities of fullerenes and endofullerenes doped with radioactive sodium iodide when they interact with calcium atoms on the outer fullerene surface (i.e., [nNa¹³¹I@C₆₀ + mCa]). The reason for investigating these calcium-functionalized (endo)fullerene systems was to gauge their potential stability when used as vectors to deliver radioiodine to cancerous tissue in the human body. In the simulations, we found that the geometric limit on the number of calcium atoms that can be physisorbed on the outer surface of an empty fullerene while maintaining its structural stability is 28 calcium atoms, which also takes into account the proportional expansion of the fullerene as the number of absorbed calcium atoms increases. However, the stability of a fullerene system during calcium adsorption also strongly depends on whether any atoms or molecules are being encapsulated by the fullerene, as these encapsulated atoms/molecules can also interact with the fullerene and influence its stability. A Mulliken electronegativity analysis revealed that, when atoms inside and/or outside the fullerene donate charge (electrons) to the fullerene, the fullerene expands. The excess charge on the carbon atoms of the fullerene weakens some of the carbon-carbon bonds, potentially causing them to break, in which case the fullerene loses its ability to encapsulate molecules and releases them. Graphical Abstract DFT simulation of a endo fullerene doped with radioactive sodium iodide interacting with 28 calcium atoms in a geometric arrangement.

Self-stability of C60 nanocapsules with radio-iodide content and its interaction with calcium atoms

This paper inquires the C60 capabilities to contain radio-iodide ((131)I2) molecules. The encapsulation conditions are investigated applying first principles method to simulate with geometric optimizations and molecular dynamics at 310 K and atmospheric pressure. We find that the n(131)I2@C60 system, where n = 1, 2, 3…, is stable if the content does not exceed three molecules of radio-iodide. The application of density functional theory allows us to determine that, the nanocapsules content limit is related with the amount of charge that is transferred from the iodine (131)I2 molecules to the carbon atoms in the fullerene surface. The Mulliken population analysis reveals that the excess of charge increases the repulsive forces between atoms and the bond length average in the C60 structure. The weakened bonds easily break and will critically damage the encapsulation properties. Additionally, we test the interaction nanocapsules with different amounts of radioactive iodine diatomic molecules content with calcium atoms, and find that only the fullerene containing one radioactive iodine diatomic molecule was able to interact with up to nine atoms of calcium without disrupting or cracking. Other fullerenes with two and three radio iodine diatomic molecules cannot resist the interaction with a single calcium atom without cracking or being broken.

Novel ethical dilemmas arising in geriatric clinical practice

The purpose of this study is to determine empirically the state of the art of the medical care, when healthcare personal is confronted with ethical dilemmas related with the care they give to the geriatric population. An observational, longitudinal, prospective and qualitative study was conducted by analyzing the correlation between healthcare personnel-patient relationship, and ethical judgments regarding dilemmas that arise in daily clinical practice with geriatric patients. Mexican healthcare personnel with current active practices were asked to write up an ethical dilemma that arose frequently or that had impacted their medical practice. From the narrative input, we were able to draw up a database with 421 dilemmas, and those corresponding to patients 60 years and older were selected (n = 54, 12.8 %). The axiological analysis of the narrative dilemmas of geriatric patients was made using dialectical empiricism. The axiological analysis values found most frequently were classified into three groups: the impact of healthcare, the roles of the physician, and refusal of therapy; the healthcare role of educator, caring for the patients' life and the risk of imminent death where the values found more often. The persistence and universality of certain dilemmas in geriatrics calls for awareness and requires a good training in the ethical discernment of these dilemmas. This would help to improve substantially the care and the life quality of this population.

New and Common Haplotypes Shape Genetic Diversity in Asian Tiger Mosquito Populations from Costa Rica and Panamá

The Asian tiger mosquito, Aedes albopictus (Skuse) (Diptera: Culicidae), is a vector of several human pathogens. Ae. albopictus is also an invasive species that, over recent years, has expanded its range out of its native Asia. Ae. albopictus was suspected to be present in Central America since the 1990s, and its presence was confirmed by most Central American nations by 2010. Recently, this species has been regularly found, yet in low numbers, in limited areas of Panamá and Costa Rica (CR). Here, we report that short sequences (∼558 bp) of the mitochondrial cytochrome oxidase subunit 1 (COI) and NADH dehydrogenase subunit 5 genes of Ae. albopictus, had no haplotype diversity. Instead, there was a common haplotype for each gene in both CR and Panamá. In contrast, a long COI sequence (∼1,390 bp) revealed that haplotype diversity (±SD) was relatively high in CR (0.72±0.04) when compared with Panamá (0.33±0.13), below the global estimate for reported samples (0.89±0.01). The long COI sequence allowed us to identify seven (five new) haplotypes in CR and two (one new) in Panamá. A haplotype network for the long COI gene sequence showed that samples from CR and Panamá belong to a single large group. The long COI gene sequences suggest that haplotypes in Panamá and CR, although similar to each other, had a significant geographic differentiation (Kst=1.33; P<0.001). Thus, most of our results suggest a recent range expansion in CR and Panamá.

Outcomes of off-label drug uses in hospitals: a multicentric prospective study

PURPOSE

The study aims to assess the clinical evidence, outcome and cost of off-label use of medicines in the hospital setting.

METHODS

A multicentric prospective cohort study of patients treated with off-label medicines was carried out in five tertiary hospitals from May 2011 to May 2012. Information on clinical characteristics of patients, drugs, outcomes and costs was collected. Patients were followed up to 6 months, and information was assessed by reviewing clinical records and interviewing physicians.

RESULTS

A total of 226 patients were included. The median (interquartile range (IQR)) age of patients was 46 (33-62) years; 59 % were women. Patients had received a median of three previous treatments, and a lack of response (or suboptimal) was the main reason for off-label use (72.1 %). A total of 232 off-label medicines were administered for 102 different indications. The most frequent medicines were rituximab (49; 21.1 %), botulinum toxin (25; 10.7 %) and omalizumab (14; 6.0 %). In 117 (51.8 %) cases, the level of clinical evidence for their use was low. A partial clinical response was observed in 82 patients (36.3 %), complete response in 71 (31.4 %) and stabilization in 11 (4.9 %). A total of 58 (26.5 %) patients had adverse effects, which in 11 (4.9 %) were severe. The median (IQR) cost per patient was 2,943.07 (541.9-5,872.54).

CONCLUSIONS

There was a high variability of off-label medicines and indications. Although the clinical evidence of off-label medicines was often low, clinical response was observed in many patients with previous multiple treatment failure, but at the expense of some adverse effects and a high cost. Registers of patients would be helpful for clinical decisions, although clinical trials are needed.

Encapsulation of sodium radio-iodide in fullerene C₆₀

In this work we have studied the well-known "Buckminsterfullerene" C₆₀ containing different amounts, from one to four molecules, of sodium radio-iodide (Na(131)I), with density functional theory geometrical optimizations and molecular dynamics at 310 K and atmospheric pressure. We found that nanocapsules with the radioactive content Na¹³¹I@C₆₀, 2Na¹³¹I@C₆₀ and 3Na¹³¹I@C₆₀ are stable. Furthermore, the C₆₀ fullerene undergoes expansion when the number of sodium radio-iodide molecules inside increases. Utilizing the Mulliken charge distribution analysis it was shown that a small charge transfer occurs from iodine to fullerene's carbon atoms. This produces repulsion which increases bond lengths thus the structure is weakened while the binding energy per atom decreases. For the case in which the fullerene initially contains four sodium radio-iodide molecules the expansion is greater than that which the structure can withstand. So the fullerene breaks and releases its contents. This result leads us to conclude that the fullerene can encapsulate up to three molecules of sodium radio-iodide.

Economic family burden of metabolic control in children and adolescents with type 1 diabetes mellitus

AIM

To appraise the economic burden for families of patients with type 1 diabetes mellitus (DM1) at the Instituto Nacional de Pediatria in Mexico City.

PATIENTS AND METHODS

DM1 family direct costs were obtained from a standardized economic survey in 59 children with no chronic severe complications such as kidney failure in 2002-3.

RESULTS

Mean family annual direct cost of treatment and monitoring was US $1689.87 which includes government funding given to both outpatients and inpatients. Despite this, DM1 out-of-pocket cost for families is very high compared to the minimum official wage of approximately $4.00 dollar/day versus $4.06 cost DM1/day. No correlation between parents' age, education or socio-economic level and direct cost was statistically significant.

CONCLUSIONS

The highest economic burden was due to self-monitoring of blood glucose (SMBG) 53.0% and insulin 14.8%. The costs were higher in children with poor metabolic control who performed SMBG less often.

[Bone marrow aplasia associated to the use of ticlopidine]

We report a 58 years old male that developed a bone marrow aplasia associated to the use of ticlopidine, prescribed after coronary artery stenting. The patient developed a pneumonia as a complication. He was admitted to the Intermediate Treatment Unit, receiving wide spectrum antimicrobial therapy and a granulocyte colony stimulating factor (Neupogen(r)) with favourable response. Ticlodipine is an effective antiplatelet agent, but has serious hematological and other side effects. Its prescription requires a close follow up and search for complications.

[Feeding and defecation of Rhodnius (hemiptera: Reduviidae) fed human blood]

Feeding and defecation behavior of Rhodnius prolixus Stal, 1859, R. robustus Larrousse, 1927, R. neivai Lent, 1953 and R. pictipes Stal, 1872, artificially fed on human blood, were studied under laboratory conditions. In all species, first instar nymphs did not defecate in the first 30 minutes after feeding. R. pictipes did not accept artificial feeding but fed directly on humans. Nymph and adult R. prolixus had a higher defecation index (DI) than other species; third instar nymphs had the highest DI = 1.62. In all instars, most individuals accepted the food in 3 Pounds minutes and finished feeding in less than 15 minutes.

[Effect of human blood feeding on the fecundity, fertility and biological cycle of Rhodnius prolixus (Hemiptera: Reduviidae)]

The effect of several human blood fractions artificially fed to Rhodnius prolixus Stal 1859 on oviposture (fecundity), egg-hatching (fertility) and life cycle was observed. Specimens fed on man's blood were more fecund than those fed with woman's blood. There were no significant differences in fertility related to host sex. The nymphal development time and number of feedings to molt to the following instar were estimated. Animals fed only on blood plasm did not finish nymphal development, while those fed only blood red cells ended their life cycle in the third nymphal instar. Total life cycle lasts 129 days in individuals fed with whole blood.

[The effect of feeding frequency on some population parameters of Rhodnius neivai]

After changing feeding frequency to a weekly and biweekly basis, a statistical evaluation of the variation of some population and reproductive parameters was conducted. It was based on four cohorts experiments of Rhodnius neivai fed on hen or rabbit. We found a direct relationship between blood feeding frequency and the parameters adult average longevity, maximum longevity and life expectancy in the animals fed on hen. On the other hand, in the insect fed biweekly on rabbit, these three values were higher than the registered in the cohorts fed weekly. Reproductive output got bigger and age-specific fertility showed a small decrease when feeding frequency was weekly. Every population parameter, except generation time, was greater in the individuals fed weekly.

[Vital statistics of Rhodnius neivai Lent, 1953 (Hemiptera: Reduviidae) under experimental conditions]

A statistical evaluation of the population dynamics of R. neivai is based on six cohorts experiments conducted under controlled laboratory conditions. Two blood sources were offered to animals: rabbit and hen. Egg hatching, nymphal development time and mortality, adult longevity and age-specific mortality, female age-specific fecundity and fertility were determined. In addition, some population parameters were evaluated, such as: life expectancy, intrinsic rate of natural increase, net reproduction rate, finite rate of increase, reproductive value and stable age distribution. Life cycle was longer in the animals fed on rabbit, nymphal survival was slightly higher in the individuals fed on hen. Age of first reproduction was lower in the insects fed on hen, but reproductive output and total number of reproductive weeks were greater in the cohorts fed on rabbit. Intrinsic and finite rate of increase were greater in the animals fed on hen. Generation time was slightly greater in the cohorts fed on rabbit. Net reproduction rate was similar on both blood sources, although it was slightly bigger in the individuals fed on rabbit. Reproductive value in the insects fed on rabbit was twice as much as the registered in the animals fed on hen.