Effect of acute high-intensity interval exercise on a mouse model of doxorubicin-induced cardiotoxicity: a pilot study

BACKGROUND

It is unknown whether high-intensity interval exercise (HIIE) may potentiate or attenuate the cardiotoxic effect of chemotherapy agents such as doxorubicin (DOX) when performed shortly after treatment. The study aimed to investigate the effect of acute HIIE on cardiac function and structure performed either 1, 2 or 3 days after DOX injection in an animal model.

METHODS

Female C57bl/6 mice (n = 28), 70 days old, received a bolus 20 mg/kg intravenous tail vein DOX injection. Three exercise groups performed 1 HIIE session (16 sets of 1 min at 85-90% of peak running speed) at 1 (n = 7), 2 (n = 7), and 3 days (n = 8) following the DOX injection. A sedentary (SED) group of mice (n = 6) did not exercise. Animals underwent echocardiography under light anesthesia (isoflurane 0.5-1%) before and 7 days after the DOX injection. Animals were sacrificed on day 9 and hearts were collected for morphometric and histological analysis.

RESULTS

Animals exercising on day 3 had the smallest pre-post reduction in left ventricular fractional shortening (LVFS) (MΔ= -1.7 ± 3.3; p = 0.406) and the SED group had the largest reduction (MΔ=-6.8 ± 7.5; p = 0.009). After reclassification of animals according to their exercise compliance (performing > 8/16 of high-intensity bouts), LVFS in compliant mice was unchanged over time (LVFS MΔ= -1.3 ± 5.6; p = 0.396) while non-compliant animals had a LVFS reduction similar to sedentary animals. There were no significant differences in myocardial histology between groups.

CONCLUSIONS

In this pilot murine study, one single HIIE session did not exacerbate acute doxorubicin-induced cardiotoxicity. The timing of the HIIE session following DOX injection and the level of compliance to exercise could influence the negative impact of DOX on cardiac function.

Transbronchial Lung Cryobiopsies, Transbronchial Forceps Lung Biopsies, and Surgical Lung Biopsies in Mechanically Ventilated Patients with Acute Hypoxemic Respiratory Failure: A Retrospective Cohort Study

IMPORTANCE

Lung biopsies are sometimes performed in mechanically ventilated patients with acute hypoxemic respiratory failure (AHRF) of unknown etiology to guide patient management. While surgical lung biopsies (SLB) offer high diagnostic rates, they may also cause significant complications. Transbronchial forceps lung biopsies (TBLB) are less invasive but often produce non-contributive specimens. Transbronchial lung cryobiopsies (TBLC) yield specimens of potentially better quality than TBLB, but due to their novel implementation in the intensive care unit (ICU), their accuracy and safety are still unclear.

OBJECTIVES

Our main objective was to evaluate the risk of adverse events in patients with AHRF following the three biopsy techniques. Our secondary objectives were to assess the diagnostic yield and associated modifications of patient management of each technique.

DESIGN, SETTINGS AND PARTICIPANTS

We conducted a retrospective cohort study comparing TBLC, TBLB, and SLB in mechanically ventilated patients with AHRF.

MAIN OUTCOMES AND MEASURES

The primary outcome was the proportion of patients with at least one complication, and secondary outcomes included complication rates, diagnostic yields, treatment modifications, and mortality.

RESULTS

Of the 26 patients who underwent lung biopsies from 2018 to 2022, all TBLC and SLB patients and 60% of TBLB patients had at least one complication. TBLC patients had higher unadjusted numbers of total and severe complications, but also worse Sequential Organ Failure Assessment scores and P/F ratios. A total of 25 biopsies (25/26, 96%) provided histopathological diagnoses, 88% (22/25) of which contributed to patient management. ICU mortality was high for all modalities (63% for TBLC, 60% for TBLB and 50% for SLB).

CONCLUSIONS AND RELEVANCE

All biopsy methods had high diagnostic yields and the great majority contributed to patient management; however, complication rates were elevated. Further research is needed to determine which patients may benefit from lung biopsies and to determine the best biopsy modality.

Defining Optimal Settings for Lung Cryobiopsy in End-Stage Pulmonary Disease. A Human, Ex Vivo, Diseased Lung Clinical Trial

BACKGROUND

To evaluate optimal settings of probe size, freezing time, and distance to the pleura that influence the size and quality of biopsy specimens during transbronchial lung cryobiopsies in ESPD.

METHODS

We prospectively recruited 17 patients undergoing lung transplantation. We created a nonperfused ex vivo bronchoscopy setting to perform multiple cryobiopsies with different probe sizes (1.7, 1.9, and 2.4 mm), freezing times (3, 5, 7, 10, 20, 30 seconds), and probe distance from pleura (5, 10, and 20 mm). Alveolated pulmonary parenchyma area≥50% in histology was considered a good quality biopsy, with a minimum procedural artifact. We used logistic regression to identify independent parameters as risk factors for histologic adequacy.

RESULTS

A total of 545 cryobiopsies were obtained from 34 explanted lungs after pneumonectomy for lung transplantation. The mean maximum diameter of the specimen achieved with the 1.7 probe was larger (13.5 mm) than those obtained with 1.9 and 2.4 mm probes (11.3 and 10.7 mm, P= 0.07). More pleural macroscopic damage and pleural tissue in histology occurred with the 2.4 mm probe ( P <0.001). There was no difference in the quality of specimens between the different freezing times and the distance from the pleura.

CONCLUSIONS

Freezing time and distance from the pleura did not affect the histologic quality for diagnosing ESPD in severely damaged lungs. Smaller cryoprobe size did not negatively affect sample adequacy.

Canadian Multicentric Pan-TRK (CANTRK) Immunohistochemistry Harmonization Study

Tumor-agnostic testing for NTRK1-3 gene rearrangements is required to identify patients who may benefit from TRK inhibitor therapies. The overarching objective of this study was to establish a high-quality pan-TRK immunohistochemistry (IHC) screening assay among 18 large regional pathology laboratories across Canada using pan-TRK monoclonal antibody clone EPR17341 in a ring study design. TRK-fusion positive and negative tumor samples were collected from participating sites, with fusion status confirmed by panel next-generation sequencing assays. Each laboratory received: (1) unstained sections from 30 cases of TRK-fusion-positive or -negative tumors, (2) 2 types of reference standards: TRK calibrator slides and IHC critical assay performance controls (iCAPCs), (3) EPR17341 antibody, and (4) suggestions for developing IHC protocols. Participants were asked to optimize the IHC protocol for their instruments and detection systems by using iCAPCs, to stain the 30 study cases, and to report the percentage scores for membranous, cytoplasmic, and nuclear staining. TRK calibrators were used to assess the analytical sensitivity of IHC protocols developed by using the 2 reference standards. Fifteen of 18 laboratories achieved diagnostic sensitivity of 100% against next-generation sequencing. The diagnostic specificity ranged from 40% to 90%. The results did not differ significantly between positive scores based on the presence of any type of staining vs the presence of overall staining in ≥1% of cells. The median limit of detection measured by TRK calibrators was 76,000 molecules/cell (range 38,000 to >200,000 molecules/cell). Three different patterns of staining were observed in 19 TRK-positive cases, cytoplasmic-only in 7 samples, nuclear and cytoplasmic in 9 samples, and cytoplasmic and membranous in 3 samples. The Canadian multicentric pan-TRK study illustrates a successful strategy to accelerate the multicenter harmonization and implementation of pan-TRK immunohistochemical screening that achieves high diagnostic sensitivity by using laboratory-developed tests where laboratories used centrally developed reference materials. The measurement of analytical sensitivity by using TRK calibrators provided additional insights into IHC protocol performance.

Consensus statement on the processing, interpretation and reporting of temporal artery biopsy for arteritis

Giant cell arteritis (GCA) is the most common systemic vasculitis in adults in Europe and North America, typically involving the extra-cranial branches of the carotid arteries and the thoracic aorta. Despite advances in noninvasive imaging, temporal artery biopsy (TAB) remains the gold standard for establishing a GCA diagnosis. The processing of TAB depends largely on individual institutional protocol, and the interpretation and reporting practices vary among pathologists. To address this lack of uniformity, the Society for Cardiovascular Pathology formed a committee tasked with establishing consensus guidelines for the processing, interpretation, and reporting of TAB specimens, based on the existing literature. This consensus statement includes a discussion of the differential diagnoses including other forms of arteritis and noninflammatory changes of the temporal artery.

Subsecond lung cancer detection within a heterogeneous background of normal and benign tissue using single-point Raman spectroscopy

Significance

Lung cancer is the most frequently diagnosed cancer overall and the deadliest cancer in North America. Early diagnosis through current bronchoscopy techniques is limited by poor diagnostic yield and low specificity, especially for lesions located in peripheral pulmonary locations. Even with the emergence of robotic-assisted platforms, bronchoscopy diagnostic yields remain below 80%.

Aim

The aim of this study was to determine whether in situ single-point fingerprint (800 to 1700    cm - 1 ) Raman spectroscopy coupled with machine learning could detect lung cancer within an otherwise heterogenous background composed of normal tissue and tissue associated with benign conditions, including emphysema and bronchiolitis.

Approach

A Raman spectroscopy probe was used to measure the spectral fingerprint of normal, benign, and cancer lung tissue in 10 patients. Each interrogated specimen was characterized by histology to determine cancer type, i.e., small cell carcinoma or non-small cell carcinoma (adenocarcinoma and squamous cell carcinoma). Biomolecular information was extracted from the fingerprint spectra to identify biomolecular features that can be used for cancer detection.

Results

Supervised machine learning models were trained using leave-one-patient-out cross-validation, showing lung cancer could be detected with a sensitivity of 94% and a specificity of 80%.

Conclusions

This proof of concept demonstrates fingerprint Raman spectroscopy is a promising tool for the detection of lung cancer during diagnostic procedures and can capture biomolecular changes associated with the presence of cancer among a complex heterogeneous background within less than 1 s.

Transbronchial Lung Cryobiopsy and Surgical Lung Biopsy: A Prospective Multi-Centre Agreement Clinical Trial (CAN-ICE)

Rationale: Transbronchial cryobiopsy (TBCB) for the diagnosis of interstitial lung disease (ILD) has shown promising results, but prospective studies with matched surgical lung biopsy (SLB) have yielded conflicting results. Objectives: We aimed to assess within- and between-center diagnostic agreement between TBCB and SLB at both the histopathologic and multidisciplinary discussion (MDD) levels in patients with diffuse ILD. Methods: In a multicenter prospective study, we performed matched TBCB and SLB in patients referred for SLB. After a blinded review by three pulmonary pathologists, all cases were reviewed by three independent ILD teams in an MDD. MDD was performed first with TBCB, then with SLB in a second session. Within-center and between-center diagnostic agreement was evaluated using percentages and correlation coefficients. Measurements and Main Results: Twenty patients were recruited and underwent contemporaneous TBCB and SLB. Within-center diagnostic agreement between TBCB-MDD and SLB-MDD was reached in 37 of the 60 (61.7%) paired observations, resulting in a Cohen's κ value of 0.46 (95% confidence interval [CI], 0.29-0.63). Diagnostic agreement increased among high-confidence or definitive diagnoses on TBCB-MDD (21 of 29 [72.4%]), but not significantly, and was more likely among cases with SLB-MDD diagnoses of idiopathic pulmonary fibrosis than fibrotic hypersensitivity pneumonitis (13 of 16 [81.2%] vs. 16 of 31 [51.6%]; P = 0.047). Between-center agreement for cases was markedly higher for SLB-MDD (κ = 0.71 [95% CI, 0.52-0.89]) than TBCB-MDD (κ = 0.29 [95% CI, 0.09-0.49]). Conclusions: This study demonstrated moderate TBCB-MDD and SLB-MDD diagnostic agreement for ILD, while between-center agreement was fair for TBCB-MDD and substantial for SLB-MDD. Clinical trial registered with www.clinicaltrials.gov (NCT02235779).

Reliability of individual acceleration-speed profile in-situ in elite youth soccer players

The aims of this study were to describe differences in the acceleration-speed (A-S) profile in-situ and to assess the week-to-week reliability of the A-S profile in-situ over a given training cycle of elite youth soccer players, in relation to the number of sessions included and analyse the effect of the inclusion or not of a specific sprint session. In this retrospective study, 18 male elite U19 football players (179.4 ± 7.1 cm; 69.0 ± 9.5 kg) participated. GPS data collected from three consecutive typical training weeks were used to calculate different combinations of A-S profile in-situ variables (theoretical maximal acceleration [A₀], theoretical maximal speed [S₀] and the slope of the acceleration-speed [AS_slope]). The number (and content) of sessions affected mainly S₀ while A₀ remained similar with or without a sprint session. The reliability of the A-S profile in-situ is more related to the spread of points rather than a specific number of sessions (and thus points) and was improved when a high percentage of maximum speed (i.e. ≥ 95%) was reached. The present study showed low week-to-week variability for A₀, S₀ and AS_slope. However, practitioners need to make sure that the values cover a sufficient range of raw data [20-95% of maximum speed] to build a clear and consistent linear regression, and in turn extrapolate meaningful A-S profile values.

Sudden cardiac death in the young: A consensus statement on recommended practices for cardiac examination by pathologists from the Society for Cardiovascular Pathology

Sudden cardiac death is, by definition, an unexpected, untimely death caused by a cardiac condition in a person with known or unknown heart disease. This major international public health problem accounts for approximately 15-20% of all deaths. Typically more common in older adults with acquired heart disease, SCD also can occur in the young where the cause is more likely to be a genetically transmitted process. As these inherited disease processes can affect multiple family members, it is critical that these deaths are appropriately and thoroughly investigated. Across the United States, SCD cases in those less than 40 years of age will often fall under medical examiner/coroner jurisdiction resulting in scene investigation, review of available medical records and a complete autopsy including toxicological and histological studies. To date, there have not been consistent or uniform guidelines for cardiac examination in these cases. In addition, many medical examiner/coroner offices are understaffed and/or underfunded, both of which may hamper specialized examinations or studies (e.g., molecular testing). Use of such guidelines by pathologists in cases of SCD in decedents aged 1-39 years of age could result in life-saving medical intervention for other family members. These recommendations also may provide support for underfunded offices to argue for the significance of this specialized testing. As cardiac examinations in the setting of SCD in the young fall under ME/C jurisdiction, this consensus paper has been developed with members of the Society of Cardiovascular Pathology working with cardiovascular pathology-trained, practicing forensic pathologists.

Dataset for the reporting of neoplasms of the heart, pericardium, and great vessels: recommendations from the International Collaboration on Cancer Reporting (ICCR)

The International Collaboration on Cancer Reporting (ICCR) was founded by major pathology organizations from around the world to produce internationally standardized and evidence-based datasets for pathologists' reporting of cancer. Its goal is to improve cancer patient outcomes worldwide and to advance international benchmarking in cancer management. The ICCR cancer dataset development schedule is aligned with revisions of the WHO Classification of Tumours ("Blue Book") series, and in 2015 ICCR developed an initial series of thoracic datasets including a dataset for neoplasms of the heart, pericardium, and great vessels. This edition has now been updated to align with the 2021 WHO Blue Book series. An expert panel was convened to review and revise the dataset. While the majority of ICCR datasets are focused on malignant tumors, the scope of this dataset includes a number of benign tumors and tumor-like entities because of the rarity of cardiac malignancies and the serious implications of even histologically benign lesions. Due to the rarity of cardiac tumors, evidence in support of reporting elements is limited.

Chronic granulomatous disease presenting at age 52 with fulminant mulch pneumonitis

Chronic granulomatous disease should be considered in adults of any age in the presence of refractory and/or atypical or fulminant pulmonary infections. This case of new large deletions in NCF1 was presented with mulch pneumonitis without a significant history of infections.

Amyloid Deposits in a Functionally Unicuspid Stenotic Aortic Valve

Amyloidosis concomitant to aortic stenosis usually occurs with myocardial infiltration by the transthyretin protein. To our knowledge, this is the first report of localized amyloidosis of indeterminate type in a severely calcified and functionally unicuspid aortic valve. Isolated dystrophic valvular amyloidosis is believed to be related to fibrocalcific valve disease. In light of the literature on this topic, the present case raises new hypotheses on pathophysiology and further supports the contributory role of unusual non-tricuspid valve morphology in the development of dystrophic amyloid, likely secondary to altered hemodynamic stress.

Effects of wearable resistance load placement on neuromuscular activity and stride kinematics: A preliminary study

Background

Wearable resistance (WR) training is a modality that allows athletes to perform loaded sport-specific movements to develop force and power outputs. The acute responses by which WR works is still relatively unknown, and the effects of WR load and location of the load has not yet been examined.

Objectives

To investigate the acute neuromuscular and stride characteristic responses to different wearable resistance (WR) loads and placements on the calf muscles during high-speed running.

Methods

Ten well-trained subjects completed a workout of ten sets of three 10s runs at 18km.h-1 (20s of rest between runs and one min between sets). Five conditions were tested: (1) unloaded control, (2) bilateral 0.75 vs. 1.5% body mass (BM) loading on the distal posterior calf, (3) bilateral proximal vs. distal loading of 1.5% BM positioned posteriorly, (4) bilateral anterior vs. posterior loading of 1.5% BM positioned distally, (5) unilateral loading of 1.5% BM on the distal posterior calf. Data were collected using Electromyography (EMG) and back-mounted GPS-embedded accelerometers. Magnitude of differences of within athlete and between muscle comparisons were calculated using effect sizes (ES) ± 90% confidence limits (CL).

Results

No substantial differences in accelerometry data were observed between any of the loaded conditions and the control. EMG activity was lower for proximal loading compared to the control for the gluteus maximus (ES±90%CL; -0.72±0.41), vastus lateralis (-0.89±0.47) and vastus medialis (VM) (-0.97±0.46). Anterior loading induced substantially lower EMG activity for the semitendinosus (-0.70±0.48) and VM (-0.64±0.39) muscles compared with the control. EMG activity of the VM (-0.73±0.46) muscle was also substantially lower for posterior loading compared to the control. Unilateral loading induced no substantial differences in EMG activity between the loaded and unloaded legs.

Conclusion

This preliminary study has provided a rationale for the performance of further investigations into the effects of WR lower limb loading on stride characteristics and EMG activity from a chronic standpoint using a larger population.

Lung Cryobiopsy Outside of the Operating Room: A Safe Alternative to Surgical Biopsy

Objective

Transbronchial lung cryobiopsy (TBLC) is a promising technique that can provide a histologic diagnosis in interstitial lung diseases (ILD) and is an alternative to surgical lung biopsy. The main concerns with the procedure are safety and diagnostic accuracy. The technique is applicable in patients unable to undergo surgical biopsy due to severe comorbidities or when patient transport to the operating room is dangerous. This study reports the initial experience with TBLC on a thoracic surgical service as a first attempt at diagnosis in patients with diffuse parenchymal lung diseases (DPLD).

Methods

Between May 2018 and July 2020, 32 patients underwent TBLC using bedside flexible bronchoscopy for suspected ILD on a thoracic surgical endoscopy service. Retrospective evaluation of the procedure details, complications, and diagnostic yield were analyzed and reported.

Results

A total of 89 pathological samples were obtained (mean 2.8 per patient). Pneumothorax and minor bleeding occurred in 25% and 16.7% of patients, respectively. Sixty-seven percent of complications occurred with use of the 2.4 mm cryoprobe (P = 0.036). Concordance between the histologic diagnosis and final clinical diagnosis was observed in 62.5% of patients and the pathology guided the final treatment in 71% (P = 0.027) with Kappa-concordance of 0.60 (P < 0.001).

Conclusions

Cryobiopsy is becoming part of the diagnostic evaluation in patients with indeterminate DPLD or hypoxemic respiratory failure. TBLC is easy to perform and has a favorable safety profile. Thoracic specialists should consider adding TBLC to their procedural armamentarium as a first option for patients with indeterminate PLD.

Invasive Mucinous Adenocarcinomas With Spatially Separate Lung Lesions: Analysis of Clonal Relationship by Comparative Molecular Profiling

INTRODUCTION

Pulmonary invasive mucinous adenocarcinomas (IMAs) often present with spatially separate lung lesions. Clonal relationship between such lesions, particularly those involving contralateral lobes, is not well established. Here, we used comparative genomic profiling to address this question.

METHODS

Patients with genomic analysis performed on two IMAs located in different lung regions were identified. Molecular assays included DNA-based next-generation sequencing (NGS) for 410 to 468 genes (Memorial Sloan Kettering-Integrated Mutation Profiling of Actionable Cancer Targets), RNA-based NGS for 62 genes (Memorial Sloan Kettering-Fusion), or non-NGS assays.

RESULTS

Comparative genomic profiling was performed on two separate IMAs in 24 patients, of whom 19 had contralateral lesions. Tumors from all but one patient shared matching driver alterations, including KRAS (n = 19), NRG1 (n = 2), ERBB2 (n = 1) or BRAF (n = 1). In addition, in patients with paired tumors profiled by NGS (n = 12), shared driver alterations were accompanied by up to 4 (average 2.6) other identical mutations, further supporting the clonal relationship between the tumors. Only in a single patient separate IMAs harbored entirely nonoverlapping mutation profiles, supporting clonally unrelated, distinct primary tumors. Notably, in a subset of patients (n = 3), molecular testing confirmed a clonal relationship between the original resected IMAs and subsequent contralateral IMA presenting after an extremely long latency (8.1-11.7 y).

CONCLUSIONS

Comparative molecular profiling supports that nearly all separate pulmonary IMA lesions represent intrapulmonary spread arising from a single tumor and documents a subset with a remarkably protracted course of intrapulmonary progression. This study reinforces the unique biology and clinical behavior of IMAs while further highlighting the value of genomic testing for clarifying the clonal relationship between multiple lung carcinomas.

Tepotinib Efficacy in a Patient with Non-Small Cell Lung Cancer with Brain Metastasis Harboring an HLA-DRB1-MET Gene Fusion

Alterations in c-MET, a tyrosine kinase receptor encoded by the MET gene, have been reported in approximately 3% of non-small cell lung cancer (NSCLC) cases and carry important treatment implications. The best studied genetic alterations are exon 14 skipping and gene amplification; however, gene rearrangement has also been described, and multiple fusion partners have been reported. Recently, in METex14-mutated NSCLC, multitarget tyrosine kinase inhibitors (TKIs), such as crizotinib and cabozantinib, as well as MET-selective TKIs, such as tepotinib and capmatinib, have demonstrated durable responses. In this study, we present the case of a 41-year-old woman with advanced NSCLC harboring an HLA-DRB1-MET gene fusion. The patient was offered successively two different MET multikinase inhibitors, crizotinib and cabozantinib, and the selective inhibitor tepotinib. Each time, including under tepotinib, the patient experienced rapid and complete responses associated with a tremendous improvement in her physical function. KEY POINTS: To our knowledge, this is the first report of a patient with non-small cell lung cancer harboring an HLA-DRB1-MET gene fusion demonstrating a clinical response to multiple MET inhibitors, including tepotinib. This finding illustrates the efficacy and rationale to targeting MET regardless of fusion partner and gives insight to pooling of patients with different MET fusion products in trials assessing safety and efficacy of novel molecules.

Developing and Validating a Primary Care EMR-based Frailty Definition using Machine Learning

Introduction

Individuals who have been identified as frail have an increased state of vulnerability, often leading to adverse health events, increased health spending, and potentially detrimental outcomes.

Objective

The objective of this work is to develop and validate a case definition for frailty that can be used in a primary care electronic medical record database.

Methods

This is a cross-sectional validation study using data from the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) in Southern Alberta. 52 CPCSSN sentinels assessed a random sample of their own patients using the Rockwood Clinical Frailty scale, resulting in a total of 875 patients to be used as reference standard. Patients must be over the age of 65 and have had a clinic visit within the last 24 months. The case definition for frailty was developed using machine learning methods using CPCSSN records for the 875 patients.

Results

Of the 875 patients, 155 (17.7%) were frail and 720 (84.2%) were not frail. Validation metrics of the case definition were: sensitivity and specificity of 0.28, 95% CI (0.21 to 0.36) and 0.94, 95% CI (0.93 to 0.96), respectively; PPV and NPV of 0.53, 95% CI (0.42 to 0.64) and 0.86, 95% CI (0.83 to 0.88), respectively.

Conclusions

The low sensitivity and specificity results could be because frailty as a construct remains under-developed and relatively poorly understood due to its complex nature. These results contribute to the literature by demonstrating that case definitions for frailty require expert consensus and potentially more sophisticated algorithms to be successful.

Abstract 368: Mechanisms of Arrhythmogenic Substrates in Lipotoxic Heart

Obesity is associated with dangerous pathologies including insulin resistance, hyperglycemia, and diabetes all of which are present as independent risks to developing fatal arrhythmias, which lead to sudden cardiac death. Cardiac lipotoxicity is a common mechanism that links these pathologies to cardiac dysfunction. The molecular mechanisms of cardiac lipotoxicity in obese heart are unknown. We investigated the effects of high-fat diet (HFD)-induced lipotoxicity on atrial electrical remodeling. Electrophysiology and rapid atrial pacing (RAP) were used to evaluate the effects of cardiac lipotoxicity in obese guinea pig hearts that show no signs of hyperglycemia or inflammation. HFD atria were associated with increased voltage-dependent potassium (I K ) and decreased L-type calcium current (I Ca,L ) densities, spontaneous beats, and increased vulnerability to atrial tachycardia with pacing. Further we see a marked reduction in I Kur and increased I K1 phenotype only after RAP. Human cardiac computer simulation studies underscore the translational relevance, as results were identical to data in lipotoxic guinea pig model. The data are the first to show that I K and I Ca,L underlie initiation of atrial arrhythmogenesis, while IK ur and IK 1 may act to sustain the arrhythmia. RNA sequencing assay in lipotoxic myocytes further revealed upregulation of PI3K and/or downregulation of AMPK as prime candidates for modulation of atrial ionic currents. The data provide a unique mechanism-based insight for targeted treatment options in patients.

Community-based Health Data Cooperatives Towards Improving the Immigrant Community Health: A Scoping Review to Inform Policy and Practice

Background

In the case of immigrant health and wellness, data are the key limiting factor, where comprehensive national knowledge on immigrant health and health service utilisation is limited. New data and data silos are an inherent response to the increase in technology in the collection and storage of data. The Health Data Cooperative (HDC) model allows members to contribute, store, and manage their health-related information, and members are the rightful data owners and decision-makers to data sharing (e g. research communities, commercial entities, government bodies).

Objective

This review attempts to scope the literature on HDC and fulfill the following objectives: 1) identify and describe the type of literature that is available on the HDC model; 2) describe the key themes related to HDCs; and 3) describe the benefits and challenges related to the HDC model.

Methods

We conducted a scoping review using the five-stage framework outlined by Arskey and O’Malley to systematically map literature on HDCs using two search streams: 1) a database and grey literature search; and 2) an internet search. We included all English records that discussed health data cooperative and related key terms. We used a thematic analysis to collate information into comprehensive themes.

Results

Through a comprehensive screening process, we found 22 database and grey literature records, and 13 Internet search records. Three major themes that are important to stakeholders include data ownership, data security, and data flow and infrastructure.

Conclusions

The results of this study are an informative first step to the study of the HDC model, or an establishment of a HDC in immigrant communities.

Key words

community health, health data, cooperative, and citizen data empowermen

Tumor CD155 Expression Is Associated with Resistance to Anti-PD1 Immunotherapy in Metastatic Melanoma

PURPOSE

Resistance to anti-PD1-based immune checkpoint blockade (ICB) remains a problem for the treatment of metastatic melanoma. Tumor cells as well as host myeloid cells can express the immune checkpoint ligand CD155 to regulate immune cell function. However, the effect of tumor CD155 on the immune context of human melanoma has not been well described. This observational study characterizes tumor CD155 ligand expression by metastatic melanoma tumors and correlates results with differences in immune cell features and response to ICB.

EXPERIMENTAL DESIGN

Pretreatment tumor specimens, from 155 patients with metastatic melanoma treated with ICB and from 50 patients treated with BRAF/MEK-directed targeted therapy, were assessed for CD155 expression by IHC. Intratumor T-cell features were analyzed using multiplex-immunohistofluorescence for CD8, PD1, and SOX10. Correlations were made between CD155 tumor level and bulk tumor RNA sequencing results, as well as clinical RECIST response and progression-free survival.

RESULTS

High pretreatment CD155 tumor levels correlated with high parenchymal PD1⁺CD8⁺/CD8⁺ T-cell ratios (PD1^tR) and poor response to anti-PD1 therapy. In PDL1 negative tumors, high CD155 tumor expression was associated with patients who had poor response to combination anti-PD1/CTLA4 therapy.

CONCLUSIONS

Our findings are the first to suggest that tumor CD155 supports an increase in the fraction of PD1⁺CD8⁺ T cells in anti-PD1 refractory melanoma tumors and, further, that targeting the CD155 pathway might improve response to anti-PD1 therapy for patients with metastatic melanoma.

Objective sleep patterns and validity of self-reported sleep monitoring across different playing levels in rugby union

Background

Growing evidence highlights that elite rugby union players experience poor sleep quality and quantity which can be detrimental for performance.

Objectives

This study aimed to i) compare objective sleep measures of rugby union players between age categories over a one week period, and ii) compare self-reported measures of sleep to wristwatch actigraphy as the criterion.

Methods

Two hundred and fifty-three nights of sleep were recorded from 38 players representing four different age groups (i.e. under 16, under 18, senior academy, elite senior) in a professional rugby union club in the United Kingdom (UK). Linear mixed models and magnitude-based decisions were used for analysis.

Results

The analysis of sleep schedules showed that U16 players went to bed and woke up later than their older counterparts (small differences). In general, players obtained seven hours of sleep per night, with trivial or unclear differences between age groups. The validity analysis highlighted a large relationship between objective and subjective sleep measures for bedtime (r = 0.56 [0.48 to 0.63]), and get up time (r = 0.70 [0.63 to 0.75]). A large standardised typical error (1.50 [1.23 to 1.88]) was observed for total sleep time.

Conclusion

This study highlights that differences exist in sleep schedules between rugby union players in different age categories that should be considered when planning training. Additionally, self-reported measures overestimated sleep parameters. Coaches should consider these results to optimise sleep habits of their players and should be careful with self-reported sleep measures.

Developing a case definition for type 1 diabetes mellitus in a primary care electronic medical record database: an exploratory study

BACKGROUND

Identifying cases of disease in primary care electronic medical records (EMRs) is important for surveillance, research, quality improvement and clinical care. We aimed to develop and validate a case definition for type 1 diabetes mellitus using EMRs.

METHODS

For this exploratory study, we used EMR data from the Southern Alberta Primary Care Network within the Canadian Primary Care Sentinel Surveillance Network (CPCSSN), for the period 2008 to 2016. For patients identified as having diabetes mellitus according to the existing CPCSSN case definition, we asked family physicians to confirm the diabetes subtype, to create the reference standard. We used 3 decision-tree classification algorithms and least absolute shrinkage and selection operator logistic regression to identify variables that correctly distinguished between type 1 and type 2 diabetes cases.

RESULTS

We identified a total of 1309 people with type 1 or type 2 diabetes, 110 of whom were confirmed by their physicians as having type 1 diabetes. Two machine learning algorithms were useful in identifying these cases in the EMRs. The first algorithm used "type 1" text words or age less than 22 years at time of initial diabetes diagnosis; this algorithm had sensitivity 42.7% (95% confidence interval [CI] 33.5%-52.5%), specificity 99.3% (95% CI 98.6%-99.7%), positive predictive value 85.5% (95% CI 72.8%-93.1%) and negative predictive value 94.9% (95% CI 93.5%-96.1%). The second algorithm used a combination of free-text terms, insulin prescriptions and age; it had sensitivity 87.3% (95% CI 79.2%-92.6%), specificity 85.4% (95% CI 83.2%-87.3%), positive predictive value 35.6% (95% CI 29.9%-41.6%) and negative predictive value 98.6% (95% CI 97.7%-99.2%).

INTERPRETATION

We used machine learning to develop and validate 2 case definitions that achieve different goals in distinguishing between type 1 and type 2 diabetes in CPCSSN data. Further validation and testing with a larger and more diverse sample are recommended.

[Vaccines for the treatment of non-small cell lung cancer]

Antigen-specific immunotherapy also known as cancer vaccination offers a novel approach for the treatment of non-small cell lung cancer patients. It relies on specific priming of the immune system in order to provoke or increase adaptive antitumor immune response against the vaccine component. Several molecules have been developed in lung cancer, based on whole-tumor cells, dendritic cells, peptides, recombinant proteins, or viral vectors. The aim of this review is to describe the mechanism of action of these vaccines and the results of the main clinical studies.

Developing a Primary Care EMR-based Frailty Definition using Machine Learning

IntroductionFrailty is a geriatric syndrome that is predictive of heightened vulnerability for disability, hospitalization, and mortality. Annually an estimated 250,000 frail Canadians die, and this estimate is expected to double in the next 40 years, as Canadians grow older. Currently there is no single accepted clinical definition of frailty. Objectives and ApproachThe objective of this study was to develop an operational definition of frailty using machine learning that can be applied to a primary care electronic medical record (EMR) database. The Canadian Primary Care Sentinel Surveillance Network (CPCSSN) is a pan-Canadian network of primary care practices that collect de-identified patient information (such as encounter diagnoses, health conditions, and laboratory data) from EMRs. 780 patients from CPCSSN have were randomly selected and assessed by physicians using the Rockwood Clinical Frailty Scale (as frail or not frail), and their clinical characteristics from CPCSSN used to develop the definition using machine-learning. ResultsA total of 8,044 clinical features were extracted from these tables: billing, problem list, encounter diagnosis, labs, medications and referrals. A chi-squared automatic interaction detector (CHAID) approach was selected as the best approach. The bootstrapping process used a cost matrix that prioritized high sensitivity and positive predictive value. 10-fold cross validation was used for validity measures. Key features factored into the algorithm included: diagnosis of dementia (ICD-9 code 290), medications furosemide and vitamins, and use of key word “obstruction” within the billing table. The validation measures with 95% confidence intervals are as follows: sensitivity of 28% (95% CI: 21% to 36%), specificity of 94% (95% CI: 93% to 96%), positive predictive value of 53% (95% CI: 42% to 64%), negative predictive value of 86% (95% CI: 83% to 88%). Conclusion/ImplicationsNo other primary care specific frailty screening tools have sufficient validity. These results suggest heterogeneous diseases require clearly defined features and potentially more sophisticated algorithms to account for heterogeneity. Further research utilizing continuous features and continuous frailty scores may be more suitable in the creation of a case detection algorithm.

Spontaneous atopic dermatitis due to immune dysregulation in mice lacking Adamts2 and 14

Since its first description, ADAMTS14 has been considered as an aminoprocollagen peptidase based on its high similarity with ADAMTS3 and ADAMTS2. As its importance for procollagen processing was never experimentally demonstrated in vivo, we generated Adamts14-deficient mice. They are healthy, fertile and display normal aminoprocollagen processing. They were further crossed with Adamts2-deficient mice to evaluate potential functional redundancies between these two highly related enzymes. Initial characterizations made on young Adamts2-Adamts14-deficient animals showed the same phenotype as that of Adamts2-deficient mice, with no further reduction of procollagen processing and no significant aggravation of the structural alterations of collagen fibrils. However, when evaluated at older age, Adamts2-Adamts14-deficient mice surprisingly displayed epidermal lesions, appearing in 2 month-old males and later in some females, and then worsening rapidly. Immunohistological evaluations of skin sections around the lesions revealed thickening of the epidermis, hypercellularity in the dermis and extensive infiltration by immune cells. Additional investigations, performed on young mice before the formation of the initial lesions, revealed that the primary cause of the phenotype was not related to alterations of the epidermal barrier but was rather the result of an abnormal activation and differentiation of T lymphocytes towards a Th1 profile. However, the primary molecular defect probably does not reside in the immune system itself since irradiated Adamts2-Adamts14-deficient mice grafted with WT immune cells still developed lesions. While originally created to better characterize the common and specific functions of ADAMTS2 and ADAMTS14 in extracellular matrix and connective tissues homeostasis, the Adamts2-Adamts14-deficient mice revealed an unexpected but significant role of ADAMTS in the regulation of immune system, possibly through a cross-talk involving mesenchymal cells and the TGFβ pathways.

Technical Advances for the Clinical Genomic Evaluation of Sudden Cardiac Death

Background—

Postmortem genetic testing for heritable cardiovascular (CV) disorders is often lacking because ideal specimens (ie, whole blood) are not retained routinely at autopsy. Formalin-fixed paraffin-embedded tissue (FFPET) is ubiquitously collected at autopsy, but DNA quality hampers its use with traditional sequencing methods. Targeted next-generation sequencing may offer the ability to circumvent such limitations, but a method has not been previously described. The primary aim of this study was to develop and evaluate the use of FFPET for heritable CV disorders via next-generation sequencing.

Methods and Results—

Nineteen FFPET (heart) and blood (whole blood or dried blood spot) specimens underwent targeted next-generation sequencing using a custom panel of 101 CV-associated genes. Nucleic acid yield and quality metrics were evaluated in relation to FFPET specimen age (6 months to 15 years; n=14) and specimen type (FFPET versus whole blood and dried blood spot; n=12). Four FFPET cases with a clinical phenotype of heritable CV disorder were analyzed. Accuracy and precision were 100% concordant between all sample types, with read depths >100× for most regions tested. Lower read depth, as low as 40×, was occasionally observed with FFPET and dried blood spot. High-quality DNA was obtained from FFPET samples as old as 15 years. Genomic analysis of FFPET from the 4 phenotype-positive/genotype unknown cases all revealed putative disease-causing variants.

Conclusions—

Similar performance characteristics were observed for next-generation sequencing of FFPET, whole blood, and dried blood spot in the evaluation of inherited CV disorders. Although blood is preferable for genetic analyses, this study offers an alternative when only FFPET is available.

Clinical and molecular characteristics of non-small-cell lung cancer (NSCLC) harboring EGFR mutation: results of the nationwide French Cooperative Thoracic Intergroup (IFCT) program

BACKGROUND

EGFR mutations cause inconsistent response to EGFR tyrosine-kinase inhibitors (TKI). To better understand these features, we reviewed all cases of EGFR-mutated non-small-cell lung cancer collected in the Biomarkers France database.

PATIENTS AND METHODS

Of 17 664 patients, 1837 (11%) with EGFR-mutated non-small-cell lung cancer were retrospectively analyzed for clinical and molecular characteristics. Results were correlated with survival and treatment response for the 848 stage IV patients.

RESULTS

EGFR exon 18, 19, 20 and 21 mutations were found in 102 (5.5%), 931 (51%), 102 (5.5%) and 702 (38%) patients, respectively. Over 50% of exon 18 and 20 mutated patients were smokers. The median follow-up was 51.7 months. EGFR mutation type was prognostic of overall survival (OS) versus wild-type {exon 19: hazard ratio (HR)=0.51 [95% confidence interval (CI): 0.41-0.64], P < 0.0001; exon 21: HR = 0.76 (95% CI: 0.61-0.95), P = 0.002; exon 20: HR = 1.56 (95% CI: 1.02-2.38), P = 0.004}. EGFR mutation type was prognostic of progression-free survival versus wild-type [exon 19: HR = 0.62 (95% CI: 0.49-0.78), P < 0.0001; exon 20: HR = 1.46 (95% CI: 0.96-2.21), P = 0.07]. First-line treatment choice did not influence OS in multivariate analysis. First-line TKI predicted improved progression-free survival versus chemotherapy [HR = 0.67 (95% CI: 0.53-0.85), P = 0.001]. OS was longer for del19 versus L858R, which was associated with better OS compared with other exon 21 mutations, including L861Q. TKI improved survival in patients with exon 18 mutations, while chemotherapy was more beneficial for exon 20-mutated patients.

CONCLUSION

EGFR mutation type can inform the most appropriate treatment. Therapeutic schedule had no impact on OS in our study, although TKI should be prescribed in first-line considering the risk of missing the opportunity to use this treatment.

[Prolonged response with paclitaxel after immunotherapy by pembrolizumab in lung cancer]

INTRODUCTION

Pembrolizumab, a humanized monoclonal antibody IgG4 anti-PD-1, having offered promising results in patients suffering from non-small cell lung cancer metastatic and heavily pretreated.

OBSERVATION

We report here the case of an unexpected good response after pembrolizumab failure obtained with paclitaxel in a 68-year-old patient with stage IV lung adenocarcinoma. Moreover, the response duration with paclitaxel was more than fourteen months.

CONCLUSION

Our case suggests a mutual potentiation of chemotherapy and immunotherapy, and raises the issue of the treatment sequence to favor.

Pneumonitis in Patients Treated With Anti-Programmed Death-1/Programmed Death Ligand 1 Therapy

Purpose Pneumonitis is an uncommon but potentially fatal toxicity of anti-programmed death-1 (PD-1)/programmed death ligand 1 (PD-L1) monoclonal antibodies (mAbs). Clinical, radiologic, and pathologic features are poorly described. Methods Patients who received anti-PD-1/PD-L1 monotherapy or in combination with anti-cytotoxic T-cell lymphocyte-4 mAb were identified at two institutions (Memorial Sloan Kettering Cancer Center: advanced solid cancers, 2009 to 2014, and Melanoma Institute of Australia: melanomas only, 2013 to 2015). Pneumonitis was diagnosed by the treating investigator; cases with confirmed malignant lung infiltration or infection were excluded. Clinical, radiologic, and pathologic features of pneumonitis were collected. Associations among pneumonitis incidence, therapy received, and underlying malignancy were examined with Fisher's exact test as were associations between pneumonitis features and outcomes. Results Of 915 patients who received anti-PD-1/PD-L1 mAbs, pneumonitis developed in 43 (5%; 95% CI, 3% to 6%; Memorial Sloan Kettering Cancer Center, 27 of 578 [5%]; Melanoma Institute of Australia, 16 of 337 [5%]). Time to onset of pneumonitis ranged from 9 days to 19.2 months. The incidence of pneumonitis was higher with combination immunotherapy versus monotherapy (19 of 199 [10%] v 24 of 716 [3%]; P < .01). Incidence was similar in patients with melanoma and non-small-cell lung cancer (overall, 26 of 532 [5%] v nine of 209 [4%]; monotherapy, 15 of 417 v five of 152 [ P = 1.0]; combination, 11 of 115 v four of 57 [ P = .78]). Seventy-two percent (31 of 43) of cases were grade 1 to 2, and 86% (37 of 43) improved/resolved with drug holding/immunosuppression. Five patients worsened clinically and died during the course of pneumonitis treatment; proximal cause of death was pneumonitis (n = 1), infection related to immunosuppression (n = 3), or progressive cancer (n = 1). Radiologic and pathologic features of pneumonitis were diverse. Conclusion Pneumonitis associated with anti-PD-1/PD-L1 mAbs is a toxicity of variable onset and clinical, radiologic, and pathologic appearances. It is more common when anti-PD-1/PD-L1 mAbs are combined with anti-cytotoxic T-cell lymphocyte-4 mAb. Most events are low grade and improve/resolve with drug holding/immunosuppression. Rarely, pneumonitis worsens despite immunosuppression, and may result in infection and/or death.

[Safety culture assessment in a university pulmonary medicine department]

INTRODUCTION

Improvement in treatment safety is a major issue in Western healthcare systems, with the aim of reducing the number of treatment associated undesirable events. The safety culture, defined as an integrated and coherent collection of individual and organizational behavior that seeks continuously to reduce harm to patients, possibly related to treatment, could fulfill this aim.

METHODS

We have used an adaption of the American "Hospital Survey on Patient Safety" questionnaire (HSOPSC), which examines professionals' perception of treatment safety, to assess the safety culture in our respiratory medicine service in the Strasbourg University Hospital.

RESULTS

Of the 110 questionnaires distributed to the service personnel, 93 were returned (85 %). The level of treatment safety was judged "acceptable" for 56 % of the personnel, "very good" for 32 %, against "weak" or "failing" for 10 %. Of the 10 dimensions explored, 8 were considered to need improvement and 2 had a level of positive responses greater than 50 %.

CONCLUSIONS

Treatment safety culture seems to be an area to develop in our service. A strong safety culture should allow health care professionals to adhere better to treatment safety mechanisms.

Unexpected post-mortem diagnosis of systemic sclerosis presenting as pneumatosis intestinalis: revised diagnostic criteria and medicolegal implications

Systemic sclerosis is a challenging diagnosis for clinicians and pathologists alike due to its protean manifestations and often insidious onset, particularly in cases without significant titres of auto-antibodies. Herein we present a case of a female in her sixties who died rapidly following a clinical diagnosis of pneumatosis intestinalis and respiratory failure of unclear etiology. Recently revised clinical diagnostic criteria were applied to the clinical history and postmortem findings to reach an unexpected diagnosis of systemic sclerosis. The diagnosis of systemic sclerosis at autopsy has important medicolegal implications largely related to premature death due to delayed treatment or poor post-operative outcome. Moreover, familial clustering of this disease underscores the importance of maintaining a high index of suspicion in the postmortem setting.

A differential dielectric affinity glucose sensor

A continuous glucose monitor with a differential dielectric sensor implanted within the subcutaneous tissue that determines the glucose concentration in the interstitial fluid is presented. The device, created using microelectromechanical systems (MEMS) technology, consists of sensing and reference modules that are identical in design and placed in close proximity. Each module contains a microchamber housing a pair of capacitive electrodes residing on the device substrate and embedded in a suspended, perforated polymer diaphragm. The microchambers, enclosed in semi-permeable membranes, are filled with either a polymer solution that has specific affinity to glucose or a glucose-insensitive reference solution. To accurately determine the glucose concentration, changes in the permittivity of the sensing and the reference solutions induced by changes in glucose concentration are measured differentially. In vitro characterization demonstrated the sensor was capable of measuring glucose concentrations from 0 to 500 mg dL(-1) with resolution and accuracy of ~1.7 μg dL(-1) and ~1.74 mg dL(-1), respectively. In addition, device drift was reduced to 1.4% (uncontrolled environment) and 11% (5 °C of temperature variation) of that from non-differential measurements, indicating significant stability improvements. Preliminary animal testing demonstrated that the differential sensor accurately tracks glucose concentration in blood. This sensor can potentially be used clinically as a subcutaneously implanted continuous monitoring device in diabetic patients.

Herpes simplex virus lymphadenitis: the elusive doppelganger in immunocompromised patients

Herpes simplex virus has protean manifestations and is an important cause of morbidity in the immunocompromised host. We report a case of recurrent lymphadenopathy and rash in a patient with chronic lymphocytic leukemia. The elusive clinical diagnosis eventually required core biopsy of a lymph node with immunohistochemistry and confirmation by polymerase chain reaction. This case illustrates the challenging clinical and laboratory diagnosis of herpes simplex virus lymphadenitis and the need to maintain a high index of suspicion for infection when treating an immunocompromised patient with unusual and/or persistent symptoms.

iPSC-derived β cells model diabetes due to glucokinase deficiency

Diabetes is a disorder characterized by loss of β cell mass and/or β cell function, leading to deficiency of insulin relative to metabolic need. To determine whether stem cell-derived β cells recapitulate molecular-physiological phenotypes of a diabetic subject, we generated induced pluripotent stem cells (iPSCs) from subjects with maturity-onset diabetes of the young type 2 (MODY2), which is characterized by heterozygous loss of function of the gene encoding glucokinase (GCK). These stem cells differentiated into β cells with efficiency comparable to that of controls and expressed markers of mature β cells, including urocortin-3 and zinc transporter 8, upon transplantation into mice. While insulin secretion in response to arginine or other secretagogues was identical to that in cells from healthy controls, GCK mutant β cells required higher glucose levels to stimulate insulin secretion. Importantly, this glucose-specific phenotype was fully reverted upon gene sequence correction by homologous recombination. Our results demonstrate that iPSC-derived β cells reflect β cell-autonomous phenotypes of MODY2 subjects, providing a platform for mechanistic analysis of specific genotypes on β cell function.