Systematic evaluation of Merkel cell carcinoma clinical practice guidelines using the AGREE II instrument

Merkel cell carcinoma (MCC) is a rare type of skin cancer that requires a multidisciplinary approach with a variety of specialists for management and treatment. Clinical practice guidelines (CPGs) have recently been established to standardize management algorithms. The objective of this study was to appraise such CPGs via the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument. Eight CPGs were identified via systematic literature search following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. Four appraisers trained in AGREE II protocols evaluated each CPG and deemed two CPGs as high quality, five as moderate quality, and one as low quality. Intraclass correlation coefficients (ICCs) were calculated to verify reviewer consistency as excellent, good, and moderate across four, one, and one domain, respectively. The majority of MCC CPGs are lacking in specifying stakeholder involvement, applicability, and rigor of development. The two high quality CPGs are from the Alberta Health Services (AHS) and the collaboration between the European Dermatology Forum, the European Association of Dermato-Oncology, and the European Organization of Research and Treatment of Cancer (EDF/EADO/EORTC). The EDF/EADO/EORTC CPG had the highest overall score with no significant deficiencies across any domain. An important limitation is that the AGREE II instrument is not designed to evaluate the validity of each CPG's recommendations; conclusions therefore can only be drawn about each CPG's developmental quality. Future MCC CPGs may benefit from garnering public perspectives, inviting external expert review, and considering available resources and implementation barriers during their developmental stages.

The efficacy of the National Surgical Quality Improvement Program surgical risk calculator in head and neck surgery: A meta-analysis

BACKGROUND

The National Surgical Quality Improvement Program surgical risk calculator (SRC) estimates the risk for postoperative complications. This meta-analysis assesses the efficacy of the SRC in the field of head and neck surgery.

METHODS

A systematic review identified studies comparing the SRC's predictions to observed outcomes following head and neck surgeries. Predictive accuracy was assessed using receiver operating characteristic curves (AUCs) and Brier scoring.

RESULTS

Nine studies totaling 1774 patients were included. The SRC underpredicted the risk of all outcomes (including any complication [observed (ob) = 35.9%, predicted (pr) = 21.8%] and serious complication [ob = 28.7%, pr = 17.0%]) except mortality (ob = 0.37%, pr = 1.55%). The observed length of stay was more than twice the predicted length (p < 0.02). Discrimination was acceptable for postoperative pneumonia (AUC = 0.778) and urinary tract infection (AUC = 0.782) only. Predictive accuracy was low for all outcomes (Brier scores ≥0.01) and comparable for patients with and without free-flap reconstructions.

CONCLUSION

The SRC is an ineffective instrument for predicting outcomes in head and neck surgery.

Managing vestibular schwannomas with radiosurgery and radiotherapy: AGREE II appraisal of clinical practice guidelines

INTRODUCTION

Vestibular schwannomas (VSs) are rare, benign intracranial tumours that have prompted clinical practice guideline (CPG) creation given their complex management. Our aim was to utilize the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument to assess if such CPGs on the management of VSs with radiosurgery and radiotherapy are of acceptable quality.

METHODS

Relevant CPGs were identified following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocols. Experienced reviewers then extracted general CPG properties and rated their quality via the AGREE II instrument. Intraclass correlation coefficients (ICCs) were quantified to assess interrater reliability.

RESULTS

Nine CPGs on the management of VSs with radiosurgery and radiotherapy were identified. All CPGs were created in the past six years and developed recommendations based on literature review and expert consensus. One guideline was deemed as high quality with seven others being moderate and one being low in quality. The clarity of the presentation domain had the highest mean scaled domain score of 96.0%. The domains of stakeholder involvement and applicability had the lowest means of 49.2% and 47.2%, respectively. ICCs were either good or excellent across all domains.

CONCLUSION

Current CPGs on the management of VSs with radiosurgery and radiotherapy are of acceptable quality but would greatly benefit from improvements in applicability, stakeholder involvement, editorial independence and rigour of development. We recommend CPG authors reference the European Association of Neuro-Oncology (EANO) guideline as a developmental framework with the Congress of Neurological Surgeons/American Association of Neurological Surgeons (CNS/AANS) CPG being a valid alternative.

Modern internet search analytics and thyroidectomy: What are patients asking?

Objectives

Thyroidectomy is among the most commonly performed head and neck surgeries, however, limited existing information is available on topics of interest and concern to patients.

Study Design

Observational.

Setting

Online.

Methods

A search engine optimization tool was utilized to extract metadata on Google-suggested questions that "People Also Ask" (PAA) pertaining to "thyroidectomy" and "thyroid surgery." These questions were categorized by Rothwell criteria and topics of interest. The Journal of the American Medical Association (JAMA) benchmark criteria enabled quality assessment.

Results

A total of 250 PAA questions were analyzed. Future-oriented PAA questions describing what to expect during and after the surgery on topics such as postoperative management, risks or complications of surgery, and technical details were significantly less popular among the "thyroid surgery" group (P < 0.001, P = 0.005, and P < 0.001, respectively). PAA questions about scarring and hypocalcemia were nearly threefold more popular than those related to pain (335 and 319 vs. 113 combined search engine response page count, respectively). The overall JAMA quality score remained low (2.50 ± 1.07), despite an increasing number of patients searching for "thyroidectomy" (r(77) = 0.30, P = 0.007).

Conclusions

Patients searching for the nonspecific term "thyroid surgery" received a curated collection of PAA questions that were significantly less likely to educate them on what to expect during and after surgery, as compared to patients with higher health literacy who search with the term "thyroidectomy." This suggests that the content of PAA questions differs based on the presumed health literacy of the internet user.

Management of the Difficult Airway: An Appraisal of Clinical Practice Guidelines

OBJECTIVE

Management of the difficult airway can be a challenging process, which necessitates actionable recommendations from well-established guidelines. Herein, clinical practice guideline (CPG) quality is evaluated using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument.

STUDY DESIGN

A systematic literature search was performed using Scopus, EMBASE, and MEDLINE via PubMed.

SETTING

Literature database.

METHODS

Data were abstracted from relevant guidelines and appraised by 4 expert reviewers in the 6 domains of quality defined by AGREE II. Intraclass correlation coefficients (ICC) were calculated across domains to quantify interrater reliability.

RESULTS

Twelve guidelines met the inclusion criteria. With a mean quality score of 83.1%, the highest quality guideline was authored by the American Society of Anesthesiologists (ASA). Low-quality content was observed in CPGs authored by the Japanese Society of Anesthesiologists (JSA) and the Chinese Collaboration Group for Emergency Airway Management (CCGEAM). Overall, deficits were most pronounced in domains describing the involvement of stakeholders, developmental rigor, and editorial independence. These findings were consistent among the panel of independent reviewers, with high ICC inter-rater reliability scores of 58.0% to 70.0% for the referenced domains.

CONCLUSION

By providing a comprehensive appraisal of guidelines, this report may serve as a reference for clinicians seeking to understand and improve upon the developmental quality of difficult airway management resources. According to AGREE II criteria for the quality of the guideline creation process, the 2022 ASA guideline outperforms its predecessors.

Radioactive Iodine in Differentiated Thyroid Carcinoma: A Systematic AGREE II Clinical Practice Guideline Appraisal

OBJECTIVE

Identify and appraise clinical practice guidelines (CPGs) for radioactive iodine (RAI) indications in differentiated thyroid carcinoma (DTC), and the treatment for radioactive iodine refractory (RAI-R) DTC using the Appraisal of Guidelines for Research and Evaluation II tool.

DATA SOURCES

MEDLINE (Pubmed), Ovid (EMBASE), and Scopus.

REVIEW METHODS

A systematic literature search was conducted to identify CPGs addressing RAI in DTC. CPGs were appraised by 4 independent reviewers in 6 distinct areas of quality. Scaled domain scores were subsequently calculated for each domain. Intraclass correlation coefficients were calculated for each domain to assess interrater reliability.

RESULTS

Sixteen guidelines were found addressing RAI indications for DTC. Of these 16, 9 also addressed the treatment of RAI-R DTC. A further 6 unique guidelines were identified that exclusively address RAI-R DTC, bringing the total number of guidelines to 22. The American Thyroid Association (ATA) guidelines for adult thyroid cancer were the highest scoring with a mean score of 83.5%. Two guidelines scored >60% in 5 or more domains, qualifying as "high" quality: ATA and British Thyroid Association. The highest scoring domain was domain 4: clarity of presentation (80.4%) while the lowest scoring domain was domain 5: applicability (38.6%).

CONCLUSION

Of the 22 guidelines identified, only two were "high quality." CPGs exclusively addressing the treatment of RAI-R DTC were weak with most guidelines scoring in the "low" quality range. This report reveals an unmet need for rigorously developed guidelines addressing indications for RAI in DTC, as well as the treatment for RAI-R DTC.

Answering head and neck cancer questions: An assessment of ChatGPT responses

PURPOSE

To examine and compare ChatGPT versus Google websites in answering common head and neck cancer questions.

MATERIALS AND METHODS

Commonly asked questions about head and neck cancer were obtained and inputted into both ChatGPT-4 and Google search engine. For each question, the ChatGPT response and first website search result were compiled and examined. Content quality was assessed by independent reviewers using standardized grading criteria and the modified Ensuring Quality Information for Patients (EQIP) tool. Readability was determined using the Flesch reading ease scale.

RESULTS

In total, 49 questions related to head and neck cancer were included. Google sources were on average significantly higher quality than ChatGPT responses (4.2 vs 3.6, p = 0.005). According to the EQIP tool, Google and ChatGPT had on average similar response rates per criterion (24.4 vs 20.5, p = 0.09) while Google had a significantly higher average score per question than ChatGPT (13.8 vs 11.7, p < 0.001) According to the Flesch reading ease scale, ChatGPT and Google sources were both considered similarly difficult to read (33.1 vs 37.0, p = 0.180) and at a college level (14.3 vs 14.2, p = 0.820.) CONCLUSION: ChatGPT responses were as challenging to read as Google sources, but poorer quality due to decreased reliability and accuracy in answering questions. Though promising, ChatGPT in its current form should not be considered dependable. Google sources are a preferred resource for patient educational materials.

Epidemiology and Management of Adult Laryngeal Trauma: An Analysis of the National Trauma Data Bank

INTRODUCTION

Laryngeal injuries are rare but life-threatening airway emergencies. Increased understanding of the epidemiology of these injuries can inform treatment and improve outcomes. We aimed to characterize the demographics and management of adult laryngeal trauma.

METHODS

The National Trauma Data Bank (NTDB) was queried from 2007 to 2015 for patients ≥18 years old with laryngeal trauma. Patient demographics, injury characteristics, and treatment course were collected. Outcomes were assessed via multivariate logistic regression.

RESULTS

From 7.3 million patients, 6,890 (0.1%) patients with laryngeal trauma were identified. Eighty-five percent of patients were male, and the median age was 40. Of these patients, 343 (5.0%) were dead on arrival and of the remaining patients, 510 (7.8%) of patients were deceased at discharge. Common concomitant injuries included facial fractures (27%), intracranial injuries (21%), and rib and sternum fractures (19%). The most common cause of injury was motor vehicle accident (26%), followed by assault with firearms/explosives (12%) and assault with cutting instruments (8%). Forty-three percent of patients received mechanical ventilation and 15% received surgical repair. After correcting for gender, age, and injury severity, firearm injuries (odds ratio [OR] 3.46, 95% CI: [2.88-4.15]) and cutting/piercing injuries (OR 2.23, 95% CI: [1.89-2.64]) were positively associated with the need for mechanical ventilation. Motor vehicle trauma (OR 0.63, 95% CI: [0.46-0.84]) was negatively associated with surgical repair while striking injuries (OR 1.61, 95% CI: [1.25-2.06]) were positively associated. Lastly, shorter time to tracheostomy was significantly associated with shorter ICU stays (p < 0.0001).

CONCLUSION

This study is the largest epidemiologic study of laryngeal trauma to date and identifies the risk of surgical intervention with firearm and cutting injuries as well as the importance of earlier time to tracheostomy for ICU management.

Human papillomavirus related oropharyngeal cancer: identifying and quantifying topics of patient interest

OBJECTIVE

As the incidence of human papillomavirus related oropharyngeal cancer continues to rise, it is increasingly important for public understanding to keep pace. This study aimed to identify areas of patient interest and concern regarding human papillomavirus and oropharyngeal cancer.

METHOD

This study was a retrospective survey of search queries containing the keywords 'HPV cancer' between September 2015 and March 2021.

RESULTS

There was 3.5-fold more interest in human papillomavirus related oropharyngeal cancer (15 800 searches per month) compared with human papillomavirus related cervical cancer (4500 searches per month). Among searches referencing cancer appearance, 96.8 per cent pertained to the head and neck region (3050 searches per month). Among vaccination searches, 16 of 47 (34.0 per cent; 600 searches per month) referenced human papillomavirus vaccines as being a cause of cancer rather than preventing cancer.

CONCLUSION

The vast majority of online searches into human papillomavirus cancer pertain to the oropharynx. There are relatively few search queries on the topic of vaccination preventing human papillomavirus associated oropharyngeal cancer, which highlights the continued importance of patient education and awareness campaigns.

Breastfeeding in primiparous women - expectations and reality: a prospective questionnaire survey

BACKGROUND

Breastfeeding provides the optimal nutrition for infants and offers numerous benefits for both mother and child. The World Health Organisation recommends exclusive breastfeeding during the first 6 months of life and the introduction of complementary feeding between the fifth and seventh months of life. There is a discrepancy between breastfeeding recommendations and the actual duration of breastfeeding. The aim of this study was to analyse breastfeeding behaviour in primiparous women in order to be able to provide support for mothers.

METHODS

In this prospective, questionnaire-based study conducted between 2020 and 2022, primiparous women were asked to complete three questionnaires at three defined survey time points (routine prepartum presentation, postpartum hospitalization, completed sixth month of life).

RESULTS

A total of 140 women were included and returned all three questionnaires. Fifty-eight percent performed breastfeeding exclusively at least until their baby had reached the age of 6 months, whereas 20% already stopped within the first 6 months. The main reasons given for early cessation were insufficient milk supply and inadequate infant weight gain. A comprehensive level of prepartum knowledge had a significant positive effect on participants' sense of confidence with breastfeeding. Sociodemographic factors such as age and educational level were also associated with breastfeeding behaviour, but significant corresponding differences in the duration of breastfeeding were not observed. Women with postpartum midwifery care breastfed significantly longer (p < 0.05).

CONCLUSIONS

Breastfeeding behaviour and duration are influenced by multiple factors. Although certain sociodemographic factors are unalterable, comprehensive prepartum knowledge transfer and postpartum midwifery care have a positive impact on breastfeeding behaviour.

TRIAL REGISTRATION

The study was retrospectively registered at the German Clinical Trials Register (Deutsches Register Klinischer Studien, DRKS) on 6 December 2022 (DRKS00030763).

Clinical practice guidelines for management of head and neck squamous cell carcinoma of unknown primary: an AGREE II appraisal

IMPORTANCE

Squamous cell carcinoma without a known primary is an uncommon form of head and neck cancer that requires multidisciplinary collaboration for effective management.

OBJECTIVE

To evaluate the quality of clinical practice guidelines (CPG) using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument.

DESIGN

A systematic literature search was performed to identify CPGs pertaining to the diagnosis and treatment of head and neck squamous cell carcinoma of unknown primary (HNSCCUP). Data were abstracted from guidelines meeting inclusion criteria and appraised by four independent reviewers in the six domains of quality defined by the AGREE II.

SETTING

Online database.

PARTICIPANTS

None.

EXPOSURE

None.

MAIN OUTCOME(S) AND MEASURE(S)

Quality domain scores and intraclass correlation coefficients (ICC) were calculated across domains to qualify inter-rater reliability.

RESULTS

Seven guidelines met inclusion criteria. Two guidelines achieved a score of > 60% in five or more AGREE II quality domains to gain designation as 'high'-quality content. One "average-quality" guideline authored by the ENT UK Head and Neck Society Council achieved a score of > 60% in three quality domains. The remaining four CPGs demonstrated low-quality content, with deficits most pronounced in domains 3 and 5, suggesting a lack of rigorously developed and clinically applicable information.

CONCLUSIONS AND RELEVANCE

As the diagnosis and treatment of head and neck cancer continues to evolve, identification of high-quality guidelines will become increasingly important. The authors recommend consulting HNSCCUP guidelines from the National Institute for Health and Care Excellence (NICE) or the American Society of Clinical Oncology (ASCO).

TRIAL REGISTRATION

None.

Wetscapes: Restoring and maintaining peatland landscapes for sustainable futures

Peatlands are among the world's most carbon-dense ecosystems and hotspots of carbon storage. Although peatland drainage causes strong carbon emissions, land subsidence, fires and biodiversity loss, drainage-based agriculture and forestry on peatland is still expanding on a global scale. To maintain and restore their vital carbon sequestration and storage function and to reach the goals of the Paris Agreement, rewetting and restoration of all drained and degraded peatlands is urgently required. However, socio-economic conditions and hydrological constraints hitherto prevent rewetting and restoration on large scale, which calls for rethinking landscape use. We here argue that creating integrated wetscapes (wet peatland landscapes), including nature preserve cores, buffer zones and paludiculture areas (for wet productive land use), will enable sustainable and complementary land-use functions on the landscape level. As such, transforming landscapes into wetscapes presents an inevitable, novel, ecologically and socio-economically sound alternative for drainage-based peatland use.

Production in peatlands: Comparing ecosystem services of different land use options following conventional farming

Majority of Dutch peatlands are drained and used intensively as grasslands for dairy farming. This delivers high productivity but causes severe damage to ecosystem services supply. Peatland rewetting is the best way to reverse the damage, but high water levels do not fit with intensive dairy production. Paludiculture, defined as crop production under wet conditions, provides viable land use alternatives. However, performance of paludiculture is rarely compared to drainage-based agriculture. Here, we compared the performances of six land use options on peatland following a gradient of low, medium, and high water levels, including conventional and organic drainage-based dairy farming, low-input grasslands for grazing and mowing, and high-input paludiculture with reed and Sphagnum cultivation. For each land use option, we conducted environmental system analysis on model farm system defined by a literature based inventory analysis. The analysis used five ecosystem services as indicators of environmental impacts with a functional unit of 1-ha peat soil. Ecosystem services included biomass provisioning, climate, water, and nutrient regulation, and maintenance of habitat. Results showed that drainage-based dairy farming systems support high provisioning services but low regulation and maintenance services. Organic farming provides higher climate and nutrient regulation services than its conventional counterpart, but limited overall improvement due to the persistent drainage. Low-intensity grassland and paludiculture systems have high regulation and maintenance services value, but do not supply biomass provisioning comparable to the drainage-based systems. Without capitalizing the co-benefits of regulation and maintenance services, and accounting for the societal costs from ecosystem disservices including greenhouse gas emission and nitrogen pollution, it is not likely that the farmers will be incentivized to change the current farming system towards the wetter alternatives. Sustainable use of peatlands urges fundamental changes in land and water management along with the financial and policy support required.

Delayed in diagnosis of upper aerodigestive tract cancers: A comprehensive review of medical malpractice cases

BACKGROUND

Factors that prompt litigation and influence outcomes for malpractice cases involving cancers of the upper aerodigestive tract are incompletely described.

METHODS

Westlaw, a national legal database, was searched for medical malpractice claims related to upper aerodigestive tract cancer for all years available.

RESULTS

Of the 122 cases meeting inclusion criteria, 106 (86.9%) involved allegations of failure to diagnose or delay in diagnosis. Tongue, larynx, and nasopharynx cancers were more frequently litigated than would be expected based on their incidence (tongue, 38.7% of aerodigestive tract litigation vs. 26.9% of aerodigestive tract cancers; larynx, 33.0% vs. 22.3%; nasopharynx, 10.4% vs. 4.6%). Payouts were made in over half of diagnosis failure lawsuits (56.6%), which carried an average award of $2840690 [IQR 850219-2537509].

CONCLUSIONS

An awareness of litigation on cancers of the upper aerodigestive tract holds the potential to improve patient care and help otolaryngologists avoid potential risks for litigation.

Nutrient dynamics of 12 Sphagnum species during establishment on a rewetted bog

Peatland degradation through drainage and peat extraction have detrimental environmental and societal consequences. Rewetting is a mitigation option to restore lost ecosystem functions, such as carbon uptake, water retention, biodiversity and nutrient sequestration. Peat mosses (Sphagnum) are the most important peat-forming species in bogs. Most Sphagnum species occur in nutrient-poor habitats, however, high growth rates have been reported in artificial nutrient-rich conditions with optimal water supply. Here, we demonstrate the differences in nutrient dynamics of 12 Sphagnum species during their establishment in a one-year field experiment at a Sphagnum paludiculture area in NW Germany. The 12 species are categorized in three groups (slower, medium and fast-growing). Rapid establishment of the peat mosses is facilitated by constant and sufficient supply of nutrient-rich, low pH, and low alkalinity surface water. Our study shows that slower-growing species (S. papillosum, S. magellancium, S. fuscum, S. rubellum, S. austinii; often forming hummocks) displayed signs of nutrient imbalance. These species accumulated higher amounts of nitrogen, phosphorus, magnesium and calcium in their capitula, and had an elevated stem N:K quotient (> 3). Additionally, this group sequestered less carbon and potassium per m² than the fast and medium growing species (S. denticulatum, S. fallax, S. riparium, S. fimbriatum, S. squarrosum, S. palustre, S. centrale). Lower lawn thickness may have amplified negative effects of flooding in slower-growing species. We conclude that nutrient dynamics and carbon/nutrient sequestration rates are species-specific. For optimal outcomes of bog restoration, generating ecosystem services or choosing suitable donor material for Sphagnum paludiculture, it is crucial to consider their compatibility with existing environmental conditions.

Rhytidectomy-Information Patients Seek and Where They Find Answers

Patients considering rhytidectomy often search for information online prior to in-office consultation. This study identifies the most searched queries regarding rhytidectomy and evaluates sources to which patients are directed. The search engine optimization tool Ahrefs was utilized to extract Google metadata on searches performed in the United States. Frequently asked questions were categorized by topic; websites were categorized by type. Journal of the American Medical Association (JAMA) benchmark criteria enabled information quality assessment. A total of 565 questions for three search phrases were extracted (265 "facelift," 265 "face lift," and 35 "rhytidectomy"). The majority of monthly searches in the facelift and face lift groups pertained to procedural cost, which was significantly higher than in the rhytidectomy group (52.9% and 50.7 vs. 0.0%, ANOVA p <0.001). The mean JAMA score for private practice sources (1.2 ± 0.42) was significantly lower than that of academic pages of (2.3 ± 1.9, p = 0.026) and commercial sources (3.0 ± 0.82, p = 0.008). The most popular destinations for rhytidectomy were California and Mexico (630 and 440 searches/month). Online searches for facelifts often revolve around the topic of cost and frequently direct patients to websites that provide inadequate information on authorship, attribution, disclosure, and currency.

Scaling Methods of the Pelvis without Distortion for the Analysis of Bone Defects

For the development of new types of hip implants for acetabulum revision, it is beneficial to analyse the acetabular defects of the indication group in advance. In order to be able to specially compare the bone defects with each other, a normalisation and accompanying scaling of the pelvis is necessary. Uniform scaling is required so that the bone structures are not distorted. In the following study, three scaling methods based on the minimal bounding box and sphere principle are compared with a method using 14 landmarks on the pelvis.The landmark method is applied to determine the true scaling factor. For the comparison of the different methods, 40 female pelvic models with an acetabular defect are analysed. In the comparison of the scaling methods, the method using minimal bounding spheres shows the least deviation from the landmark method (mean difference 3.30 ± 2.17 %). Due to the fact that no preprocessing (definition of the landmarks) is required and the fast implementation of the algorithm, the minimal bounding sphere is to be preferred to the landmark method for a fast size estimation.

Clinical practice guidelines for management of medullary thyroid carcinoma: An AGREE II appraisal

PURPOSE

Medullary thyroid carcinoma (MTC) is a rare and aggressive form of thyroid neoplasia that requires multidisciplinary collaboration for effective management. We systematically appraise the quality of clinical practice guidelines (CPG) for the diagnosis and treatment of MTC using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument.

MATERIALS AND METHODS

A systematic literature search was performed to identify CPGs pertaining to the diagnosis and treatment of MTC. Data were abstracted from guidelines meeting inclusion criteria and appraised by four independent reviewers in the six domains of quality defined by the AGREE II. Intraclass correlation coefficients (ICC) were calculated across domains to qualify interrater reliability.

RESULTS

Fourteen guidelines met inclusion criteria. No guideline achieved a score of >60 % in five or more AGREE II quality domains, which is required to gain designation as 'high' quality. One "average quality" guideline authored by the British Thyroid Association achieved a score of >60 % in three quality domains. The remaining thirteen (92.9 %) CPGs demonstrated low quality content, with deficits most pronounced in domains 3, 5, and 6, suggesting a lack of rigorously developed, clinically applicable, and transparent information.

CONCLUSIONS

As the diagnosis and treatment of MTC continues to evolve, the development of high-quality guidelines becomes increasingly important; few existing meet appropriate standards.

Sphagnum bleaching: Bicarbonate 'toxicity' and tolerance for seven Sphagnum species

Growth and functioning of Sphagnum mosses are closely linked to water level and chemistry. Sphagnum mosses occur in wet, generally acidic conditions, and when buffered, alkaline water is known to negatively impact Sphagnum. The effects of time, dose and species-specific responses of buffered, alkaline water on Sphagnum are largely unknown. We investigated the effects of bicarbonate and calcium on the survival, growth and physiological functioning of seven Sphagnum species occurring in contrasting environments, from raised bogs to (rich) fens. Mosses were submerged in different concentrations of bicarbonate and calcium solutions for 10 weeks under climate-controlled circumstances. After 2 weeks, all species exposed to the high bicarbonate treatment (2.0 mM) showed severe potassium leakage and swift discoloration. In contrast, species showed differential responses to the intermediate bicarbonate treatment (0.8 mM), some with a later onset of potassium leakage. S. squarrosum, S. teres & S. contortum generally persisted the longest, with all species dying after 6 to 10 weeks. Calcium alone, in contrast, negatively affected S. squarrosum, S. teres & S. contortum, causing discoloration and potassium leakage. Our study shows enrichment with bicarbonate, but not calcium, is detrimental for most Sphagnum species tested. A mechanistic model was developed that is consistent with dose and duration dependence and the species specificity. Future conservation and restoration measures for Sphagnum-dominated habitats and Sphagnum farming (cultivation, production and harvest of Sphagnum moss biomass) should limit flooding with bicarbonate-rich waters while investigating new management options, like acidifying surface waters to lower bicarbonate levels.

Recovering wetland biogeomorphic feedbacks to restore the world's biotic carbon hotspots

Biogeomorphic wetlands cover 1% of Earth's surface but store 20% of ecosystem organic carbon. This disproportional share is fueled by high carbon sequestration rates and effective storage in peatlands, mangroves, salt marshes, and seagrass meadows, which greatly exceed those of oceanic and forest ecosystems. Here, we review how feedbacks between geomorphology and landscape-building vegetation underlie these qualities and how feedback disruption can switch wetlands from carbon sinks into sources. Currently, human activities are driving rapid declines in the area of major carbon-storing wetlands (1% annually). Our findings highlight the urgency to stop through conservation ongoing losses and to reestablish landscape-forming feedbacks through restoration innovations that recover the role of biogeomorphic wetlands as the world's biotic carbon hotspots.

A Systematic Review of Cervical Ganglioneuromas

Objective

To perform a systematic review of the literature evaluating clinical characteristics and management of cervical ganglioneuromas (CGNs).

Data Sources

PubMed, Embase, and Cochrane Library databases were searched. Data such as patient demographics, imaging, and treatments were obtained.

Review Methods

Pertinent studies were downloaded, and the full text was reviewed by 4 authors (N.P., S.S., C.F., D.T.). Results were reported via the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-analyses).

Results

Fifty-two studies with 58 patients were identified in the literature. Of the 58 patients, 22 were adults and 36 were pediatric. The most common reported location of CGN was within the parapharyngeal space (76%), followed by the retropharyngeal (19%) and paravertebral/prevertebral (7%) spaces. The most common presenting symptoms included a nontender mass (29.3%), dysphagia (17.2%), and hoarseness (10.3%). Interestingly, the average tumor volume for patients with postoperative Horner’s syndrome was 183 mm3 (n = 21, 47.7%) vs 946 mm3 in patients without Horner’s syndrome (n = 23, 52.3%). This represents a statistically significant finding ( P = .018). There exists no significant difference in tumor volumes between adult and pediatric patients with Horner’s syndrome ( P = .645).

Conclusion

CGN is a rare tumor of the sympathetic nervous system. Management should involve complete surgical excision with biopsy. We found that patients with small-volume CGNs are significantly more likely to experience postoperative Horner’s syndrome. This finding is independent of age and should therefore be taken into consideration in any patient with suspected CGN.

First record of the sound produced by the oldest Upper Paleolithic seashell horn

Anthropologists and ethnomusicologists assert that there is no society without song, and more specifically, there is no ritual or celebration without accompanying sound. The production of sounds in social contexts is very ancient. Here, we report on the study of a seashell from the decorated cave of Marsoulas and demonstrate that the Magdalenian occupants of this site transformed this shell into a wind instrument. It is one of the very rare examples, if not the only one for the Paleolithic period, of a musical instrument fashioned from a large shell, and the first conch shell of this use thus far discovered. We already know that prehistoric people transformed many shells into portable ornaments and that they thus attributed substantial corporal symbolism to them. This seashell horn, with its unique sonority, both deep and strong with an enduring reverberation, sheds light on a musical dimension until now unknown in the context of Upper Paleolithic societies.

Shape Accuracy and Surface Quality of Additively Manufactured, Optimized, Patient-Specific Bone Plates

Powder-based additive manufacturing technologies such as powder bed fusion (PBF) using a laser beam (PBF-LB) and PBF using an electron beam (PBF-EB) allow the manufacturing of complex, patient-specific implants from titanium alloys at appropriate manufacturing expenses and thus production cost. To meet medical quality requirements, mechanical post-treatment (e.g., grinding and polishing) is often required. However, different medical applications require specific quality characteristics. It is therefore necessary to assess the fulfillment of the requirements for each case individually with regard to the manufacturing technologies. This study investigated the potential of the two mentioned additive manufacturing technologies for manufacturing patient-specific, topology-optimized bone plates that are used for osteosynthesis (the joining of bone segments) in the reconstruction of the mandible (lower jaw). Identical individualized implants were manufactured and subsequently treated with established industrial processes and examined according to medical quality requirements. Crucial quality requirements for this medical application are the shape accuracy (for exact bone positioning and even load transmission) as well as the surface quality (to enhance fatigue strength and prevent bone ingrowth in view of the subsequent easy removal of the plates). The machining of the implants is shown in comparison to distinguish the two manufacturing processes from established procedures.

Nutrient removal potential and biomass production by Phragmites australis and Typha latifolia on European rewetted peat and mineral soils

Paludiculture, sustainable and climate-smart land use of formerly drained, rewetted organic soils, can produce significant biomass in peatlands whilst potentially restoring several additional wetland services. However, the site conditions that allow maximum biomass production and nutrient removal by paludiculture crops have rarely been studied. We studied the relationship between soil characteristics, including plant-available nutrients, peak biomass, stand age, harvest period, and nutrient removal potential for two important paludiculture species, Typha latifolia and Phragmites australis, on rewetted peat and mineral soils in a large-scale European survey. T. latifolia and P. australis were able to produce an aboveground peak biomass of 10-30 t dry matter ha^-1 y^-1 and absorbed significant amounts of carbon, nitrogen, phosphorus, and potassium in stands older than 3 years. They were able to grow in a wide range of abiotic soil conditions. Low N:P ratios (5-9) and low N content (< 2%) in T. latifolia tissue suggest N limitation, but P uptake was still surprisingly high. P. australis had higher N:P ratios (8-25) and was less responsive to nutrients, suggesting a higher nutrient use efficiency. However, both species could still produce significant biomass at lower nutrient loads and in winter, when water content was low and nutrient removal still reasonable. Based on this European wetland survey, paludiculture holds a great potential to combine peat preservation, water purification, nutrient removal, and a high biomass production. Paludicrops take up substantial amounts of nutrients, and both summer and winter harvests provide an effective way to sequester carbon in a range of high-valued biomass products and to control nutrient effluxes from rewetted sites at the landscape scale.

Burnout in medical students

Only a small number of studies have examined the relationship between medical students and burnout syndrome. In Salzburg, Paracelsus Private Medical University (PMU) offers a 5‑year medical program instead of the regular 6 years of medical studies. Due to the tight schedule and heavy workload, the stress level of students is high. The purpose of this study was to determine whether PMU students show burnout symptoms. Three surveys were conducted: at the beginning of the academic year (T1, December 2009), at the end of the academic year (T2, June 2010), and at the beginning of the following academic year (T3, December 2010). For the assessment of burnout, the Maslach Burnout Inventory (emotional exhaustion, depersonalization or cynicism, and low personal accomplishment) was used, as well as the Six Factors Theory of Burnout (workload, control, reward, community, fairness, and values) and for comparison, the Austrian norms developed by Unterholzer. Burnout rate was calculated by a combined measure of the three components. The results show a significant difference from the norm means in emotional exhaustion, depersonalization/cynicism, and low personal accomplishment. With regard to areas of work life, all values are below the means, indicating high workload, high external control, low reward, low feeling of community, and low fairness—except values, i.e., motivation of the students. The mean overall burnout frequency turned out to be 47.8 ± 11.0%, whereas females have slightly higher burnout rates than males. An increasing linear trend with burnout rates was seen from the youngest to the oldest class. In addition, the estimated burnout rate increased within the academic term, as T2 had the highest rate, followed by T3, and the lowest rate was seen in T1. In conclusion, burnout in medical students is frequent and significantly related to heavy workload and other factors of worklife, necessitating changes of academic and organizational settings of medical curricula.

Nutrient dynamics of Sphagnum farming on rewetted bog grassland in NW Germany

The agricultural use of drained peatlands leads to huge emissions of greenhouse gases and nutrients. A land-use alternative that allows rewetting of drained peatland while maintaining agricultural production is the cultivation of Sphagnum biomass as a renewable substitute for fossil peat in horticultural growing media (Sphagnum farming). We studied Sphagnum productivity and nutrient dynamics during two years in two Sphagnum farming sites in NW Germany, which were established on drained bog grassland by sod removal, rewetting, and the introduction of Sphagnum fragments in 2011 and 2016, respectively. We found a considerable and homogeneous production of Sphagnum biomass (>3.6 ton DW ha^--1 yr^-1), attributable to the high nutrient levels, low alkalinity, and even distribution of the irrigation water. The ammonium legacy from former drainage-based agriculture rapidly declined after rewetting, while nutrient mobilization was negligible. CH₄ concentrations in the rewetted soil quickly decreased to very low levels. The Sphagnum biomass sequestered high loads of nutrients (46.0 and 47.4 kg N, 3.9 and 4.9 kg P, and 9.8 and 16.1 kg K ha^-1 yr^-1 in the 7.5 y and 2.5 y old sites, respectively), preventing off-site eutrophication. We conclude that Sphagnum farming as an alternative for drainage-based peatland agriculture may contribute effectively to tackling environmental challenges such as local and regional downstream pollution and global climate change.

Variation in symbiotic N2 fixation rates among Sphagnum mosses

Biological nitrogen (N) fixation is an important process supporting primary production in ecosystems, especially in those where N availability is limiting growth, such as peatlands and boreal forests. In many peatlands, peat mosses (genus Sphagnum) are the prime ecosystem engineers, and like feather mosses in boreal forests, they are associated with a diverse community of diazotrophs (N2-fixing microorganisms) that live in and on their tissue. The large variation in N2 fixation rates reported in literature remains, however, to be explained. To assess the potential roles of habitat (including nutrient concentration) and species traits (in particular litter decomposability and photosynthetic capacity) on the variability in N2 fixation rates, we compared rates associated with various Sphagnum moss species in a bog, the surrounding forest and a fen in Sweden. We found appreciable variation in N2 fixation rates among moss species and habitats, and showed that both species and habitat conditions strongly influenced N2 fixation. We here show that higher decomposition rates, as explained by lower levels of decomposition-inhibiting compounds, and higher phosphorous (P) levels, are related with higher diazotrophic activity. Combining our findings with those of other studies, we propose a conceptual model in which both species-specific traits of mosses (as related to the trade-off between rapid photosynthesis and resistance to decomposition) and P availability, explain N2 fixation rates. This is expected to result in a tight coupling between P and N cycling in peatlands.

A Critical Analysis of the Information Available Online for Ménière’s Disease

Objective

Patients increasingly rely on online resources for medical information; however, the Internet is unregulated and prone to misinformation. This study analyzes the reliability, quality, and readability of websites for Ménière’s disease.

Study Design

A Google search was performed using keywords Ménière’s disease. The first 5 pages (50 results) were reviewed. Websites were sorted into 5 categories: academic institutions, government agencies, professional organizations, medical information websites, and miscellaneous. The reliability, quality, and readability of each website were evaluated using the DISCERN instrument and Flesch-Kincaid Grade Level (FKGL). DISCERN assesses reliability and quality by scoring 15 questions on a scale from 1 (low) to 3 (high). The reliability score emphasizes clear objectives and sources, as well as lack of bias, whereas the quality score emphasizes information on treatment options. The FKGL of each website was calculated using a formula to determine the equivalent US grade reading level.

Setting

Ambulatory.

Subjects

None.

Results

Forty-two websites were analyzed. Academic institutions were the most common (n = 13, 31%) but scored the lowest using DISCERN at 1.75 ± 0.13. Medical information websites scored highest at 2.24 ± 0.09 ( P = .024 compared to academic institutions). The average FKGL of all websites was 10.12 ± 0.57 with medical information websites being the easiest to read at 8.84 ± 0.83. Only 5 (13%) of websites scored below the eighth-grade reading level.

Conclusions

Most top online search results for Ménière’s disease are deficient in quality and readability. Medical information websites are generally the most reliable and easy to read.

ATM activity in T cells is critical for immune surveillance of lymphoma in vivo

The proximal DNA damage response kinase ATM is frequently inactivated in human malignancies. Germline mutations in the ATM gene cause Ataxia-telangiectasia (A-T), characterized by cerebellar ataxia and cancer predisposition. Whether ATM deficiency impacts on tumor initiation or also on the maintenance of the malignant state is unclear. Here, we show that Atm reactivation in initially Atm-deficient B- and T cell lymphomas induces tumor regression. We further find a reduced T cell abundance in B cell lymphomas from Atm-defective mice and A-T patients. Using T cell-specific Atm-knockout models, as well as allogeneic transplantation experiments, we pinpoint impaired immune surveillance as a contributor to cancer predisposition and development. Moreover, we demonstrate that Atm-deficient T cells display impaired proliferation capacity upon stimulation, due to replication stress. Altogether, our data indicate that T cell-specific restoration of ATM activity or allogeneic hematopoietic stem cell transplantation may prevent lymphomagenesis in A-T patients.

β-bloquants dans la prise en charge du choc septique

Les adrénorécepteurs α et en particulier β sont les principales cibles de l’adrénaline et de la noradrénaline libérées par le système sympathique activé. Durant le choc septique, la dysautonomie est une stimulation prolongée à un haut niveau d’intensité du système nerveux sympathique à l’origine d’une altération de la contractilité, de la vasoréactivité et d’une immunodépression. Ainsi, l’administration précoce d’un traitement β-bloquant lors du choc septique pourrait pondérer les effets délétères de cette surstimulation sympathique. Néanmoins, si les preuves expérimentales sont en faveur de cette approche, l’accumulation des preuves cliniques reste encore insuffisante.

Abstract P1-09-08: BCL2L1 (BCL-XL) expression and MYC super-enhancer positivity predict sensitivity to the covalent CDK7 inhibitor SY-1365 in triple negative breast cancer (TNBC) cell lines

Effective therapies for TNBC remain elusive. As such, TNBCs are associated with a high risk of relapse and short progression free- and overall-survival. Recent studies showed that TNBC cells are highly dependent on the transcriptional regulator CDK7, and suggest that the mitochondrial apoptosis pathway is important in mediating cell survival in CDK7-dependent cells. Further, TNBC has been shown to have a distinct epigenetic and transcriptional program, with super-enhancers (SE) mediating the expression of key oncogenic drivers such as MYC. SY-1365, a covalent and selective inhibitor of CDK7, was developed to exploit dysregulated programs thought to drive SE-mediated transcriptional-dependencies in TNBC and other cancers. To identify potential biomarkers predictive of sensitivity to SY-1365, we evaluated SY-1365 inhibitory activity in a large panel of human tumor cell lines, including TNBC lines, and correlated sensitivity with RNA expression and epigenetic profiles.

SY-1365 dose-response curves were measured using the ATP-lite assay in a panel of 406 human tumor cell lines, including 19 TNBC cell lines. Clustering of growth-rate adjusted dose response curves of cell-lines treated with SY-1365 allowed the classification of cell-lines into low and high response groups. An unbiased genome wide approach was used to compare response classification to RNA expression data across all cell lines to identify gene expression markers predictive of sensitivity to SY-1365. Furthermore, a hypothesis driven approach was followed to interrogate whether the MYC SE predicted sensitivity to SY-1365.

Twenty-five genes were differentially expressed between SY-1365-sensitive and -insensitive tumor lines (FDR&lt;0.05). Lower expression of BCL2L1, which encodes the mitochondrial apoptosis regulator BCL-XL, was identified as the most predictive expression biomarker of sensitivity across all profiled cell lines, strongly separating the two classes of sensitivity (Accuracy=70%, FDR&lt;0.005). Further, this predictive power of lower BCL2L1 expression was maintained in an analysis restricted to the subset of TNBC cell-lines (Accuracy=73%).

Expanding beyond expression analysis, we also found that the strength of the MYC SE (as defined by H3K27Ac) was predictive of response to SY-1365 in TNBC (Accuracy=86%, FDR&lt;0.05).

In this study, we show for the first time that SY-1365 induced differential responses across a large panel of human tumor cell lines derived from multiple indications. We also show that in this panel of cell lines the response could be predicted in an “indication agnostic” manner by the level of expression of BCL2L1. Finally, in line with prior reports, in TNBC cell lines, MYC SE was significantly associated with sensitivity to SY-1365. These observations have generated strong hypotheses for selection strategies aimed at identifying patients with tumors particularly sensitive to CDK7 inhibition with SY-1365, and warrant further investigation with respect to predictive biomarkers of response in patients. SY-1365 is currently being assessed in a phase 1 trial in adult patients with advanced solid tumors, including a planned expansion cohort enriching for patients with TNBC (NCT03134638).

Citation Format: Rajagopal N, Hodgson G, Hu S, McKeown M, Bush A, Fritz C, Orlando D, Olson E, di Tomaso E. BCL2L1 (BCL-XL) expression and MYC super-enhancer positivity predict sensitivity to the covalent CDK7 inhibitor SY-1365 in triple negative breast cancer (TNBC) cell lines [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P1-09-08.

Abstract B171: PK/PD modeling of the first-in-class, potent and selective covalent CDK7 inhibitor, SY-1365, provides mechanistic basis for intermittent dosing regimens in preclinical efficacy models of hematologic and solid tumors

Introduction: CDK7 has recently emerged as an attractive gene control target in cancers driven by transcriptional dependencies, including triple-negative breast cancer (TNBC) and acute myeloid leukemia (AML). SY-1365 is a first-in-class, potent, and selective covalent CDK7 inhibitor that has shown durable and complete responses in xenograft models of AML and various solid tumors. To advance the development of this CDK7 inhibitor in patients, the current work assessed the relationship between SY-1365 pharmacokinetics (PK), pharmacodynamics (PD) measured as CDK7 target occupancy, and efficacy in mouse xenograft models of AML (HL-60) and TNBC (HCC70). Methods: SY-1365 was dosed intravenously in several xenograft experiments across a range of dose levels (5-40 mg/kg) and dose frequencies (daily to weekly). PK and changes in CDK7 occupancy were measured following single and repeat dosing, and efficacy studies measured the resultant dose-dependent changes in tumor volume over time after repeat dosing of SY-1365. To account for the temporal differences in PK, PD and tumor growth inhibition (TGI), a mathematical modeling approach was taken to integrate the resulting datasets. In addition, an assay to determine CDK7 occupancy in human PBMCs was developed to support the ongoing phase 1 study. Results: The PK in mouse was proportional with respect to dose and exhibited a terminal elimination half-life (t1/2) of 4 h. The PK/PD model was able to describe the PK, PD, and efficacy in HL-60 and HCC70 xenografts, with similar exposure and CDK7 occupancy profiles observed in these two xenografts. The model demonstrated a CDK7 turnover t1/2 of 69 h, longer than that reported for other oncogenic kinases targeted with covalent inhibitors where daily dosing is required (e.g., EGFRi, BTKi), with optimal efficacy achieved when target engagement was sustained over the dosing interval. This provides a mechanistic basis for intermittent dosing based on the dose-dependent TGI, including tumor regressions, observed with SY-1365 in in vivo models of TNBC and AML. Conclusions: The PK/PD relationship for target engagement and efficacy of the first-in-class potent and selective covalent CDK7 inhibitor, SY-1365, has been characterized in preclinical models through a mathematical modeling approach. Assays were developed to enable target occupancy quantification in xenograft tumors, and in human PBMCs as a surrogate tissue to support clinical investigation. Further investigations into tumor molecular profiles driving response are currently under way. In summary, this work supported the selection of an initial twice-weekly dosing regimen in the ongoing phase 1 trial of SY-1365 in adult patients with advanced solid tumors (NCT03134638).

Citation Format: Nigel J. Waters, Shanhu Hu, Brett Matzuka, Graeme Hodgson, Yixuan Ren, Yoon Choi, Kevin Dykstra, Christopher Roberts, Kevin Sprott, Emmanuelle di Tomaso, Christian Fritz. PK/PD modeling of the first-in-class, potent and selective covalent CDK7 inhibitor, SY-1365, provides mechanistic basis for intermittent dosing regimens in preclinical efficacy models of hematologic and solid tumors [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2017 Oct 26-30; Philadelphia, PA. Philadelphia (PA): AACR; Mol Cancer Ther 2018;17(1 Suppl):Abstract nr B171.

Effects of airborne ammonium and nitrate pollution strongly differ in peat bogs, but symbiotic nitrogen fixation remains unaffected

Pristine bogs, peatlands in which vegetation is exclusively fed by rainwater (ombrotrophic), typically have a low atmospheric deposition of reactive nitrogen (N) (<0.5kgha^-1y^-1). An important additional N source is N₂ fixation by symbiotic microorganisms (diazotrophs) in peat and mosses. Although the effects of increased total airborne N by anthropogenic emissions on bog vegetation are well documented, the important question remains how different N forms (ammonium, NH₄⁺, versus nitrate, NO₃^-) affect N cycling, as their relative contribution to the total load strongly varies among regions globally. Here, we studied the effects of 11years of experimentally increased deposition (32 versus 8kgNha^-1y^-1) of either NH₄⁺ or NO₃^- on N accumulation in three moss and one lichen species (Sphagnum capillifolium, S. papillosum, Pleurozium schreberi and Cladonia portentosa), N₂ fixation rates of their symbionts, and potential N losses to peat soil and atmosphere, in a bog in Scotland. Increased input of both N forms led to 15-90% increase in N content for all moss species, without affecting their cover. The keystone species S. capillifolium showed 4 times higher N allocation into free amino acids, indicating N stress, but only in response to increased NH₄⁺. In contrast, NO₃^- addition resulted in enhanced peat N mineralization linked to microbial NO₃^- reduction, increasing soil pH, N concentrations and N losses via denitrification. Unexpectedly, increased deposition from 8 to 32kgha^-1y^-1 in both N forms did not affect N₂ fixation rates for any of the moss species and corresponded to an additional input of 5kgNha^-1y^-1 with a 100% S. capillifolium cover. Since both N forms clearly show differential effects on living Sphagnum and biogeochemical processes in the underlying peat, N form should be included in the assessment of the effects of N pollution on peatlands.

Radial oxygen loss by the cushion plant Eriocaulon schimperi prevents methane emissions from an East-African mountain mire

Groundwater-fed fens are known sources of methane (CH₄ ) emissions to the atmosphere, and these are known to be mediated by the vegetation. In a fen located in the Bale Mountains, Ethiopia, we assessed the effects of a cushion plant (Eriocaulon schimperi) and a sedge (Carex monostachya) on rhizosphere biogeochemistry. Methane and CO₂ concentrations and pH were measured in pore-water at different depths in the profile. Redox potentials and NaCl-extractable element concentrations were analysed in soil samples from sites dominated by either E. schimperii or C. monostachya. Nutrient and element concentration were analysed in plant tissues. At Carex-dominated sites, CH₄ concentrations increased from 70 μmol·l^-1 at a depth of 10 cm to 130 μmol·l^-1 at a depth of 100 cm. CH₄ concentrations at Eriocaulon-dominated sites were almost zero (<1 μmol·l^-1 ) to a depth of 100 cm. Simultaneously, soil redox potentials and CO₂ concentrations were higher at Eriocaulon-dominated sites, indicating a low potential for CH₄ production and a high potential for CH₄ oxidation. Eriocaulon schimperi displayed a root investment strategy to cope with the harsh environment, similar to the cushion plant Astelia pumila in Patagonian bogs. This strategy is characterised by high root/shoot ratios, high root porosity and density under high redox conditions. Both cushion plant species create an aerobic rhizosphere through radial oxygen loss from deep roots, which strongly reduce CH₄ fluxes to the atmosphere.

Two mouse models reveal an actionable PARP1 dependence in aggressive chronic lymphocytic leukemia

Chronic lymphocytic leukemia (CLL) remains an incurable disease. Two recurrent cytogenetic aberrations, namely del(17p), affecting TP53, and del(11q), affecting ATM, are associated with resistance against genotoxic chemotherapy (del17p) and poor outcome (del11q and del17p). Both del(17p) and del(11q) are also associated with inferior outcome to the novel targeted agents, such as the BTK inhibitor ibrutinib. Thus, even in the era of targeted therapies, CLL with alterations in the ATM/p53 pathway remains a clinical challenge. Here we generated two mouse models of Atm- and Trp53-deficient CLL. These animals display a significantly earlier disease onset and reduced overall survival, compared to controls. We employed these models in conjunction with transcriptome analyses following cyclophosphamide treatment to reveal that Atm deficiency is associated with an exquisite and genotype-specific sensitivity against PARP inhibition. Thus, we generate two aggressive CLL models and provide a preclinical rational for the use of PARP inhibitors in ATM-affected human CLL.

ATM and TP53 mutations are associated with poor prognosis in chronic lymphocytic leukaemia (CLL). Here the authors generate mouse models of Tp53- and Atm-defective CLL mimicking the high-risk form of human disease and show that Atm-deficient CLL is sensitive to PARP1 inhibition.

Abstract 1143: Targeting the transcriptional kinases CDK12 and CDK13 in breast and ovarian cancer

CDK12 and CDK13 regulate expression of large transcripts requiring substantial processing to produce mature mRNA. This transcriptional regulation includes coordinated phosphorylation of specific repeats within the C-terminal domain of RNA polymerase II and association with RNA processing factors (Chila, 2016). RNAi knockdown of CDK12 in cell culture decreases expression of DNA damage response genes, including BRCA1 and ATR, while enhancing sensitivity to DNA damaging agents (Blazek, 2011; Liang, 2015). Recently THZ531, a selective covalent inhibitor of CDK12 and CDK13, was shown to decrease expression of DNA damage response genes in cell culture (Zhang, 2016). Here we present further studies with THZ531 to guide our discovery program toward molecules suitable for clinical development and to explore mechanistic rationales for combining a CDK12/13 inhibitor with PARP inhibitors or DNA damaging agents for difficult-to-treat cancers such as high-grade serous ovarian cancer and triple-negative breast cancer. Using THZ531 as a benchmark, we developed assays capable of discriminating sub-nM inhibitors, including quantifying time-dependent covalent inhibition and cell-based CDK occupancy. Since CDK7, like CDK12 and CDK13, contains a cysteine residue proximal to the kinase active site, these approaches are critical to understand covalent inhibitor selectivity. Furthermore, we performed kinome paneling studies to better understand selectivity of this scaffold in support of our ongoing efforts to optimize CDK12/13 potency and selectivity. To pharmacologically investigate the previously reported effects of CDK12 RNAi, growth inhibition of a panel of ovarian and breast cancer cell lines was assessed following treatment with THZ531 (OVA EC50 = 50-200 nM (n=6); BRCA EC50 &lt;50 nM (n=4)). Expression profiling revealed that THZ531 treatment resulted in different sets of genes being affected than was observed following treatment with inhibitors targeting CDK7, CDK9 or BET-bromodomain proteins. Additionally, CDK12/13, CDK7 and CDK9 inhibitors were profiled in a broad cell line panel (n&gt;400) to reveal relationships between inhibitor sensitivity, mutation status, gene expression, and potential oncology indications that may be addressed by these different mechanisms. Finally THZ531 was synergistic with both PARP inhibitors and DNA damaging agents in ovarian and breast cancer cell lines. These data highlight cancer indications and combinations that may be particularly amenable to treatment with CDK12/13 inhibitors. While the pharmacokinetic properties of THZ531 preclude adequate target engagement in tumor tissue at tolerated doses in mouse model systems, our ongoing medicinal chemistry program is progressing to identify and optimize CDK12/13 inhibitors suitable for clinical evaluation.

Citation Format: Michael Bradley, Jason Marineau, Yoon Choi, Kristin Hamman, Goran Malojcic, David Orlando, Yixuan Ren, Nan Ke, Shanhu Hu, Eric Olson, Christian Fritz, Christopher Roberts. Targeting the transcriptional kinases CDK12 and CDK13 in breast and ovarian cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 1143. doi:10.1158/1538-7445.AM2017-1143

Abstract 2644: SY-1425, a selective RARα agonist, induces high levels of CD38 expression in RARA-high AML tumors creating a susceptibility to anti-CD38 therapeutic antibody treatment

CD38 is a cell surface protein expressed primarily on white blood cells and considered a marker of differentiation initiation. CD38 is involved in the immune system by engaging cross-talk with T and B cells as well as activation of NK cells. In multiple myeloma (MM), a subset of tumor cells have high CD38 expression (CD38hi), which has led to the development of effective anti-CD38 therapeutic antibodies, such as daratumumab (DARA). Thus, cancer cells that express CD38 can be selectively targeted for elimination by the immune system using these therapeutic antibodies. In multiple myeloma, DARA is most effective in patients whose tumor cells are CD38hi. In contrast, CD38 expression in AML tumors is generally observed to be negative (CD38neg) or dim (CD38dim), and DARA has not shown activity in preclinical AML models. We previously reported that SY-1425, a clinical stage RARα agonist with improved pharmacokinetics, potency, and selectivity over pan-retinoic acid agonists, induces differentiation in non-APL AML cell lines and primary patient samples with a RARA super-enhancer associated biomarker (RARA-high). Since CD38 was found to be among the most differentially expressed genes in response to SY-1425, we hypothesized that SY-1425 mediated CD38 induction to levels comparable to MM may sensitize RARA-high AML cells to anti-CD38 therapy. We demonstrate that SY-1425 treatment of four RARA-high AML cell lines and four RARA-high primary AML patient PBMCs induces the CD38hi phenotype, as measured by flow cytometry, similar to that found in the DARA sensitive MM cells. In contrast, we see no induction in RARA-low cell lines. We then demonstrated the activity of the SY-1425 and DARA combination in an ex vivo NK cell co-culture assay. Two RARA-high AML cell lines treated with SY-1425 and DARA were co-cultured with NK cells and monitored for both antibody dependent cell-mediated cytotoxicity (ADCC) and NK cell activation by interferon gamma production. The combination of SY-1425 and DARA led to a six-fold increase in tumor cell death relative to the single agent controls, and 5-10 fold increases in NK cell activation is observed only in the SY-1425 and DARA combination treatment of RARA-high AML cell lines. Neither single agent, when administered alone, resulted in ADCC. Furthermore, a RARA-low AML cell line does not respond in the ADCC assay following the combination treatment due to the lack of CD38 induction in this SY-1425 insensitive line. In summary, we have identified a novel and rational combination treatment approach for a subset of patients with RARA-high AML. By inducing the expression of CD38, SY-1425 in combination with DARA elicits tumor cell death and NK cell activation. Based on these findings, a phase 2 clinical study with SY-1425 in combination with an anti-CD38 antibody is planned in AML using an RARA biomarker patient selection strategy.

Citation Format: Kathryn Austgen, Michael R. McKeown, Darren Smith, Emily Lee, Chris Fiore, Matthew L. Eaton, Christian Fritz, Tracey Lodie, Eric Olson. SY-1425, a selective RARα agonist, induces high levels of CD38 expression in RARA-high AML tumors creating a susceptibility to anti-CD38 therapeutic antibody treatment [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 2644. doi:10.1158/1538-7445.AM2017-2644

Automated Process Planning for CNC Machining

This article describes our application of AI planning to the problem of automated process planning for machining parts, given raw stock and a CAD file describing the desired part geometry. We have found that existing planners from the AI community were falling short on several requirements, most importantly regarding the expressivity of state and action representations, and the ability to exploit domain-specific knowledge to prune the search space. In this article we describe the requirements we had in this application and what kind of results from the planning community helped us most. Overall, in this project as well as others, we found that even significant results from domain-independent planning may not be relevant in practice.