Classification and treatment of vaginal strictures at the donor-recipient anastomosis after uterus transplant

OBJECTIVE

To describe the incidence and management of vaginal stricture after uterus transplants (UTx) in the United States, to propose a grading system to classify stricture severity, and to identify risk factors for stricture formation.

DESIGN

Prospective cohort study.

SUBJECTS

Recipients undergoing UTx from 2016 to 2023 at Baylor University Medical Center at Dallas, Cleveland Clinic, University of Pennsylvania, and University of Alabama at Birmingham were monitored postoperatively with regular pelvic exams. Stricture was defined as vaginal narrowing less than 3 cm in patients with graft survival of at least 7 days.

EXPOSURE

Demographic and surgery characteristics.

MAIN OUTCOME MEASURES

Stricture development and severity (Grade 1 for diameter 2 to <3 cm, Grade 2 for 1 to <2 cm, or Grade 3 for <1 cm).

RESULTS

Of the 45 UTx from 2016 to 2023 (16 deceased donor, 29 living donor), 3 were excluded from the analysis due to graft loss within 7 days. Of the 42 remaining recipients, 39 (92.9%) had Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome and 3 (7.1%) had a prior hysterectomy. Twenty-eight UTx recipients (66.7%) developed postoperative vaginal strictures with median time to stricture of 33 days (interquartile range 19 to 53 days). Most strictures were of moderate severity, with 4 strictures (14.3%) categorized as Grade 1, 19 (67.9%) as Grade 2, and 5 (17.9%) as Grade 3. History of MRKH and preoperative recipient vaginal length were significant risk factors for stricture, after adjustment for donor and recipient age and BMI, anastomosis technique, total ischemia time, center, and year. Patients with longer preoperative vaginal length had a lower risk of stricture (HR 0.45, 0.29-0.70). Severity grading of the stricture was associated with effectiveness of a non-operative treatment approach (p=0.018, Grade 1 vs. Grade 3). No patients with Grade 3 strictures improved with self-dilation alone; all required surgical repair and/or dilation under anesthesia. Conversely, for Grade 1 or 2 strictures, self-dilation alone was successful in 47.8% (11/23), and no Grade 1 strictures required surgical repair.

CONCLUSIONS

Vaginal stricture is a common postoperative complication after UTx, affecting over 65% of recipients. Short preoperative vaginal length and history of Müllerian agenesis in the recipient are significant risk factors. Vaginal self-dilation was effective for some mild to moderate strictures, though dilation under anesthesia or surgical repair was required in most cases.

Targeting Tryptophan Catabolism in Ovarian Cancer to Attenuate Macrophage Infiltration and PD-L1 Expression

High-grade serous carcinoma (HGSC) of the fallopian tube, ovary, and peritoneum is the most common type of ovarian cancer and is predicted to be immunogenic because the presence of tumor-infiltrating lymphocytes conveys a better prognosis. However, the efficacy of immunotherapies has been limited because of the immune-suppressed tumor microenvironment (TME). Tumor metabolism and immune-suppressive metabolites directly affect immune cell function through the depletion of nutrients and activation of immune-suppressive transcriptional programs. Tryptophan (TRP) catabolism is a contributor to HGSC disease progression. Two structurally distinct rate-limiting TRP catabolizing enzymes, indoleamine 2,3-dioxygenase 1 (IDO1) and tryptophan 2,3-dioxygenase 2 (TDO2), evolved separately to catabolize TRP. IDO1/TDO2 are aberrantly expressed in carcinomas and metabolize TRP into the immune-suppressive metabolite kynurenine (KYN), which can engage the aryl hydrocarbon receptor to drive immunosuppressive transcriptional programs. To date, IDO inhibitors tested in clinical trials have had limited efficacy, but those inhibitors did not target TDO2, and we find that HGSC cell lines and clinical outcomes are more dependent on TDO2 than IDO1. To identify inflammatory HGSC cancers with poor prognosis, we stratified patient ascites samples by IL6 status, which correlates with poor prognosis. Metabolomics revealed that IL6-high patient samples had enriched KYN. TDO2 knockdown significantly inhibited HGSC growth and TRP catabolism. The orally available dual IDO1/TDO2 inhibitor, AT-0174, significantly inhibited tumor progression, reduced tumor-associated macrophages, and reduced expression of immune-suppressive proteins on immune and tumor cells. These studies demonstrate the importance of TDO2 and the therapeutic potential of AT-0174 to overcome an immune-suppressed TME.

SIGNIFICANCE

Developing strategies to improve response to chemotherapy is essential to extending disease-free intervals for patients with HGSC of the fallopian tube, ovary, and peritoneum. In this article, we demonstrate that targeting TRP catabolism, particularly with dual inhibition of TDO2 and IDO1, attenuates the immune-suppressive microenvironment and, when combined with chemotherapy, extends survival compared with chemotherapy alone.

Malpractice litigation surrounding in vitro fertilization in the United States: a legal literature review

IMPORTANCE

Analysis of malpractice lawsuits that involve in vitro fertilization (IVF) can provide insight into the breadth of legal challenges faced by IVF clinics and the patient harms and financial consequences that can result from alleged errors in practice.

OBJECTIVE

We aimed to review malpractice litigations involving IVF and identify common themes in plaintiff allegations and defense arguments.

EVIDENCE REVIEW

We queried Nexis Uni, Westlaw, and CourtListener legal databases to collect records from malpractice litigations involving IVF. The nature of the cases, allegations, and outcomes were abstracted from court documents.

FINDINGS

Of the 447 cases identified in the query, 53 involved both malpractice and IVF, occurring between 1993 and 2022. Defendants included a reproductive endocrinologist in 19 (35.8%) cases, an academic institution in 17 (32.1%) cases, embryology personnel in 9 (17.0%) cases, and nursing staff in 2 (3.8%) cases. Twenty-four (45.3%) cases involved embryology errors (e.g., lost specimens and incorrect sperm donor), 11 (20.8%) preimplantation genetic testing errors (e.g., child born with genetic illness despite testing), 6 (11.3%) medical or surgical complications (e.g., ovarian hyperstimulation syndrome), 4 (7.5%) misdiagnoses (e.g., malignancy before cycle start), 3 (5.6%) misrepresentations of IVF outcomes, 2 (3.8%) medical eligibility screening issues (e.g., medical comorbidities in a gestational carrier), 2 (3.8%) confidentiality breaches, and 1 (1.9%) case of discrimination. The most common secondary claims were negligence (23 cases, 16.4% of all claims), breach of contract (13, 9.3%), lack of informed consent (11, 7.9%), and negligent infliction of emotional distress (11, 7.9%). Twenty-nine (54.7%) cases were decided in favor of the defending IVF clinic or provider, 13 (24.5%) cases were decided in favor of the plaintiff, and 11 (20.8%) involved ongoing proceedings. Financial awards ranged from $4171 to $14,975,000, with the largest monetary award resulting from a cryostorage accident class action lawsuit.

CONCLUSION

In vitro fertilization malpractice claims are varied, with the most common issues involving embryology laboratory processes and genetic testing errors. Some errors may be avoidable with increased vigilance and implementation of stringent laboratory and clinical guidelines. Understanding jurisdiction-specific legislation and court processes may also assist IVF providers in navigating the malpractice litigation process.

RELEVANCE

This comprehensive review of IVF litigation may have the potential to promote practices that protect both providers and patients.

The Complete Genome Sequence of Adansonia digitata (Malvaceae, Malvales), the African Baobab

Adansonia digitata, the African Baobab, is a long-lived tree species found in sub-Saharan Africa. We present the whole genome sequence of this species. Illumina paired-end reads were assembled by a de novo method followed by a finishing step. The raw and assembled data are publicly available via GenBank: Sequence Read Archive (SRR23340274) and assembled genome (JAQSVH000000000).

Counselling, Research Gaps, and Ethical Considerations Surrounding Pregnancy in Solid Organ Transplant Recipients

Survival after solid-organ transplantation has improved significantly, and many contemporary transplant recipients are of childbearing potential. There are limited data to guide decision-making surrounding pregnancy after transplantation, variations in clinical practice, and significant knowledge gaps, all of which raise significant ethical issues. Post-transplant pregnancy is associated with an increased risk of maternal and fetal complications. Shared decision-making is a central aspect of patient counselling but is complicated by significant knowledge gaps. Stakeholder interests can be in conflict; exploring these tensions can help patients to evaluate their options and inform their deliberations. We argue that uniform, evidence-based recommendations for pregnancy after solid organ transplantation are needed. Conducting research, including patient-engaged studies, in this area should be priority for the transplant community.

The Complete Genome Sequences of 94 Species of Parrots (Psittaciformes, Aves)

We present the complete genome sequences of 94 species of parrots from 40 genera. Illumina sequencing was performed on genetic material from single individuals. The reads were assembled using a de novo method followed by a finishing step. The raw and assembled data is publicly available via Genbank.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Abstract TP135: Prehospital Transport Protocol For Comprehensive Stroke Center Triage Is Associated With Reduced Last Known Well To Arrival Times For Intracranial Hemorrhage

Background: In September 2018, we implemented a prehospital routing protocol for patients with suspected severe stroke and large vessel occlusion using the 3 Item Stroke Scale (3I-SS). Patients who have a 3I-SS score of ≥4 and have a known last normal time of ≤6 hours were transported to the closest Comprehensive Stroke Center (CSC). While the impact on endovascular treatment for ischemic stroke is more established, the effect of this transport policy on patients with intracerebral hemorrhage (ICH) is unknown.

Objective/Methods: The objective of the study was to determine if implementation of a regional CSC transport protocol reduced last known well (LKW) to hospital arrival time for patients with ICH.Data was retrospectively reviewed all patients with a primary diagnosis of ICH from Get With The Guidelines® (GWTG) Stroke regional registry between January 2018 to May 2019 (8 month pre and 8 months post-implementation) and consisting of 16 Primary Stroke Centers (PSCs) and 8 CSCs. We analyzed LKW-arrival times to compare median times in the pre- vs. post-implementation periods.

Results: There were 501 ICH cases in the pre-implementation period (mean age 66, 43.3% Black, and 52.3% male) and 548 in the post-implementation period (mean age 66, 41.0% Black, and 54.3% male). In the post-implementation period, median LKW to hospital arrival time was 255 minutes vs. 270.5 minutes in the pre-implementation period (P value 0.029). LKW to hospital arrival times for those patients arriving from EMS decreased from a median 112.5 minutes to 81 minutes (P value 0.034).

Conclusions: A prehospital direct-to-CSC transport protocol resulted in a substantial decrease in the median LKW to hospital arrival times for ICH patients, driven especially by EMS-arriving patients. Prehospital protocols could increase access to time sensitive life-saving therapies for ICH.

The Complete Genome Sequence of Chlorophytum comosum (Asparagaceae, Asparagales), the Spider Plant

Chlorophytum comosum is a species of evergreen perennial flowering plant native to tropical and southern Africa but has become naturalized in other parts of the world, including western Australia and Bangladesh. We present the whole genome sequence of Chlorophytum comosum. Illumina paired-end reads were assembled by a de novo method followed by a finishing step. The raw and assembled data are publicly available via GenBank: Sequence Read Archive (SRR11638255) and assembled genome (GCA_025212335).

Prehospital Comprehensive Stroke Center vs Primary Stroke Center Triage in Patients With Suspected Large Vessel Occlusion Stroke

Importance

Endovascular therapy (EVT) improves functional outcomes in acute ischemic stroke (AIS) with large vessel occlusion (LVO). Whether implementation of a regional prehospital transport policy for comprehensive stroke center triage increases use of EVT is uncertain.

Objective

To evaluate the association of a regional prehospital transport policy that directly triages patients with suspected LVO stroke to the nearest comprehensive stroke center with rates of EVT.

Design, Setting, and Participants

This retrospective, multicenter preimplementation-postimplementation study used an interrupted time series analysis to compare treatment rates before and after implementation in patients with AIS arriving at 15 primary stroke centers and 8 comprehensive stroke centers in Chicago, Illinois, via emergency medical services (EMS) transport from December 1, 2017, to May 31, 2019 (9 months before and after implementation in September 2018). Data were analyzed from December 1, 2017, to May 31, 2019.

Interventions

Prehospital EMS transport policy to triage patients with suspected LVO stroke, using a 3-item stroke scale, to comprehensive stroke centers.

Main Outcomes and Measures

Rates of EVT before and after implementation among EMS-transported patients within 6 hours of AIS onset.

Results

Among 7709 patients with stroke, 663 (mean [SD] age, 68.5 [14.9] years; 342 women [51.6%] and 321 men [48.4%]; and 348 Black individuals [52.5%]) with AIS arrived within 6 hours of stroke onset by EMS transport: 310 of 2603 (11.9%) in the preimplementation period and 353 of 2637 (13.4%) in the postimplementation period. The EVT rate increased overall among all patients with AIS (preimplementation, 4.9% [95% CI, 4.1%-5.8%]; postimplementation, 7.4% [95% CI, 7.5%-8.5%]; P < .001) and among EMS-transported patients with AIS within 6 hours of onset (preimplementation, 4.8% [95% CI, 3.0%-7.8%]; postimplementation, 13.6% [95% CI, 10.4%-17.6%]; P < .001). On interrupted time series analysis among EMS-transported patients, the level change within 1 month of implementation was 7.15% (P = .04) with no slope change before (0.16%; P = .71) or after (0.08%; P = .89), which indicates a step rather than gradual change. No change in time to thrombolysis or rate of thrombolysis was observed (step change, 1.42%; P = .82). There were no differences in EVT rates in patients not arriving by EMS in the 6- to 24-hour window or by interhospital transfer or walk-in, irrespective of time window.

Conclusions and Relevance

Implementation of a prehospital transport policy for comprehensive stroke center triage in Chicago was associated with a significant, rapid, and sustained increase in EVT rate for patients with AIS without deleterious associations with thrombolysis rates or times.

Life underneath the VCA umbrella: Perspectives from the US Uterus Transplant Consortium

The parallel emergence of uterus transplantation (UTx) and other transplantation innovations including face and hand transplantation led to the categorization of the uterus as a vascular composite allograft (VCA). With >60 transplants and >20 births worldwide, UTx is transitioning rapidly from a research endeavor to an effective treatment option for women with uterine factor infertility. While it originally made sense to group the innovations under one umbrella, it is time to revisit the designation of UTx as a VCA. We describe how UTx needs unique policy, procedural codes, insurance contracts, and educational initiatives. We contend that separating UTx from VCAs may become necessary in the future to avoid hindering the growth and regulation of this field.

Guidelines for standardized nomenclature and reporting in uterus transplantation: An opinion from the United States Uterus Transplant Consortium

Uterus transplantation is a nascent but growing field. To support this growth, the United States Uterus Transplant Consortium proposes guidelines for nomenclature related to operative technique, vascular anatomy, and donor, recipient, and offspring outcomes. In terms of anatomy, the group recommends reporting donor arterial inflow and recipient anastomotic site delivering inflow to the graft and offers standardization of the names for the 4 veins originating from the uterus because of current inconsistency in this particular nomenclature. Seven progressive stages with milestones of success are defined for reporting on uterus transplantation outcomes: (1) technical, (2) menstruation, (3) embryo implantation, (4) pregnancy, (5) delivery, (6) graft removal, and (7) long-term follow-up. The 3 primary metrics for success are recipient survival (as reported for other organ transplant recipients), graft survival, and uterus transplant live birth rate (defined as live birth per transplanted recipient). A number of secondary outcomes should also be reported, most of which capture stage-specific milestones, as well as data on graft failure. Outcome metrics for living donors include patient survival, survival free of operative intervention, and data on complications and hospitalizations. Finally, we make specific recommendations on follow-up for offspring born from uterine grafts, which includes specialty surveillance as well as collection and reporting of routine pediatric outcomes. The goal of standardization in reporting is to create consistency and improve the quality of evidence available on the efficacy and value of the procedure.

The complete genome sequence of Stevia rebaudiana, the Sweetleaf

The Sweetleaf ( Stevia rebaudiana: Asteraceae) is widely grown for use as a sweetener.  We present the whole genome sequence and annotation of this species.  A total of 146,838,888 paired-end reads consisting of 22.2G bases were obtained by sequencing one leaf from a commercially grown seedling.  The reads were assembled by a de-novo method followed by alignment to related species.   Annotation was performed via GenMark-ES. The raw and assembled data is publicly available via GenBank: Sequence Read Archive ( SRR6792730) and Assembly ( GCA_009936405).

Abstract TP385: Using a Learning Collaborative Model in Metro Chicago to Identify Best Practice Strategies for Emerging Topics: E-Cigarette Use in Stroke Patients

Background: While learning collaborative models have been shown to aid implementation of published national guidelines, less is known about their role in informing health care providers about emerging topics not yet written into guidelines. National guidelines state that stroke patients who have a history of smoking should receive smoking cessation intervention prior to hospital discharge. However, guidelines do not include recommendations related to e-cigarette use. Launched July 2018, the Metro Chicago Smoking Cessation Initiative was a one-year pilot aimed at improving understanding of smoking cessation interventions provided at discharge, smoking behavior post-discharge, and best practices for reducing smoking rates at 20 Chicago area hospitals. While hospital practices and patient behavior around e-cigarettes was not an aim, the learning collaborative model enabled hospital participants to report their experiences and enact practice changes related to e-cigarettes.

Methods: The pilot used a Learning Collaborative model that included a quality improvement leader, health behavior content experts, reporting of experiences and data, and sharing of best practices. Pilot participating hospitals were required to attend quarterly online learning sessions and use Get With The Guidelines® Stroke for data entry. Hospitals documented smoking cessation intervention provided at time of discharge and contacted patients via phone at 30 days post-discharge to gather data on current smoking use, quit attempts, and therapies used. Hospitals completed a baseline questionnaire reporting current smoking cessation practices and a mid-point questionnaire reporting changes to practice and experiences as a pilot participant. Responses were reviewed for themes related to e-cigarettes.

Results: See Table 1

Conclusions: A Learning Collaborative Model may be a method for identifying strategies for practice changes prior to guideline recommendations.

Abstract TP313: A Metro Chicago Learning Collaborative Model to Improve Smoking Cessation Rates in Stroke Patients

Background: National guidelines for stroke care recommend that patients discharged with a stroke who have a history of smoking receive smoking cessation intervention prior to hospital discharge. However, less is known about the types of intervention provided and subsequent outcomes post-discharge. The Metro Chicago Smoking Cessation Initiative Pilot aimed to improve understanding of smoking cessation interventions provided at discharge, smoking behavior at 30 days post-discharge, and best practices and barriers for reducing smoking rates in stroke patients discharged from 20 Chicago area hospitals.

Methods: A review of smoking cessation interventions provided at discharge and smoking cessation outcomes post-discharge for stroke patients discharged between August 1, 2018 and July 31, 2019 at 20 Chicago area participating hospitals was conducted using Get With The Guidelines® Stroke. The pilot used a Learning Collaborative model that included a quality improvement leader, smoking cessation/health behavior content experts, reporting of experiences and data, and sharing of best practices. All hospitals were required to attend quarterly online learning sessions and use Get With The Guidelines® Stroke for data entry.

Results: Preliminary results from the 20 participating hospitals suggest smoking cessation counseling is the most commonly delivered intervention at discharge. Of the patients reached at 30 days post-discharge, 75% of those who reported at history of smoking at the time of their stroke were still using tobacco products. However, nearly 50% of those patients reported having made at least one attempt to quit.

Conclusions: Preliminary results from this pilot project highlight the need for improved tracking of smoking cessation interventions provided at discharge and associated smoking behavior post-discharge, as well as the benefits of regional collaboration for identifying and implementing best practices.

NCBI Taxonomy: a comprehensive update on curation, resources and tools

The National Center for Biotechnology Information (NCBI) Taxonomy includes organism names and classifications for every sequence in the nucleotide and protein sequence databases of the International Nucleotide Sequence Database Collaboration. Since the last review of this resource in 2012, it has undergone several improvements. Most notable is the shift from a single SQL database to a series of linked databases tied to a framework of data called NameBank. This means that relations among data elements can be adjusted in more detail, resulting in expanded annotation of synonyms, the ability to flag names with specific nomenclatural properties, enhanced tracking of publications tied to names and improved annotation of scientific authorities and types. Additionally, practices utilized by NCBI Taxonomy curators specific to major taxonomic groups are described, terms peculiar to NCBI Taxonomy are explained, external resources are acknowledged and updates to tools and other resources are documented. Database URL: https://www.ncbi.nlm.nih.gov/taxonomy.

RefSeq: an update on prokaryotic genome annotation and curation

The Reference Sequence (RefSeq) project at the National Center for Biotechnology Information (NCBI) provides annotation for over 95 000 prokaryotic genomes that meet standards for sequence quality, completeness, and freedom from contamination. Genomes are annotated by a single Prokaryotic Genome Annotation Pipeline (PGAP) to provide users with a resource that is as consistent and accurate as possible. Notable recent changes include the development of a hierarchical evidence scheme, a new focus on curating annotation evidence sources, the addition and curation of protein profile hidden Markov models (HMMs), release of an updated pipeline (PGAP-4), and comprehensive re-annotation of RefSeq prokaryotic genomes. Antimicrobial resistance proteins have been reannotated comprehensively, improved structural annotation of insertion sequence transposases and selenoproteins is provided, curated complex domain architectures have given upgraded names to millions of multidomain proteins, and we introduce a new kind of annotation rule—BlastRules. Continual curation of supporting evidence, and propagation of improved names onto RefSeq proteins ensures that the functional annotation of genomes is kept current. An increasing share of our annotation now derives from HMMs and other sets of annotation rules that are portable by nature, and available for download and for reuse by other investigators. RefSeq is found at https://www.ncbi.nlm.nih.gov/refseq/.

Abstract P2-01-04: Epithelial-mesenchymal transition promotes triple negative breast cancer immune suppression

Background: Epithelial-Mesenchymal Transition (EMT) is a developmental process co-opted by carcinomas to facilitate metastasis. Triple negative breast cancer (TNBC), which has often undergone at least partial EMT, has a poor prognosis due to frequent and rapid recurrence as metastatic disease when compared to other breast cancer subtypes. To identify drivers of TNBC progression microRNA miR-200c was restored to the human TNBC mesenchymal-like BT549 cell line, which decreased 80% of the pan-EMT mesenchymal signature and restored 60% of the epithelial signature. In addition to decreasing proteins involved in immune-suppression via contact-dependent mechanisms, such as CD274 (PD-L1) and (CD273) PD-L2, Ingenuity Pathway and GSEA analysis revealed reduced expression of genes encoding enzymes, including Tryptophan 2,3-Dioxygenase (TDO2) and Heme Oxygenase-1 (HO-1), that generate immune-suppressive metabolites that function in a non-contact dependent manner. TNBC utilizes these and other immune-suppressive factors made by fetal trophoblasts to suppress the maternal immune system to achieve fetal tolerance during pregnancy, suggesting that TNBC may mimic a physiologically relevant mechanism to promote immune evasion.

Hypothesis: TNBC metabolism is altered as part of an EMT program resulting in generation of immune-suppressive metabolites that promote metastasis by facilitating contact-independent immune evasion.

Methods: Expression and activity of TDO2 and HO-1 were determined by UHPLC-MS for kynurenine (generated by TDO2) and bilirubin (generated by HO-1) in multiple TNBC cell lines. Single cell RNAseq was performed to identify genes co-expressed with these enzymes. To develop an immune competent preclinical model, doxycycline inducible miR-200c (TripZ-200c) was stably introduced into the Met-1 mammary carcinoma cell line derived from the MMTV-PyMT mouse model developed in FVB/NJ mice. Results were confirmed via transient miR-200c expression in 66cl-4 mammary carcinoma cells (from a spontaneous BALB/c tumor).

Results: Restoration of miR-200c decreased TDO2 and HMOX1 (HO-1) by 80% and 40% respectively in Met-1 and 66cl-4 mammary carcinoma cells and reduced secretion of kynurenine and bilirubin. HO-1 was increased in lung metastasis from Met-1 and 66cl-4 cells when compared to cells prior to tail vein injection. ScRNAseq revealed specific gene expression signatures co-expressed with TDO2 and are being analyzed to better detect TDO2 in tumor tissues. In vivo studies are underway to investigate the effects of inhibiting tumor TDO2 and HO-1 on infiltrating lymphocyte composition, the anti-tumor immune response, and tumor progression.

Conclusions: Restoration of miR-200c revealed EMT-associated alterations in tumor metabolism and consequent secretion of immune-suppressive metabolites produced by TDO2 and HO-1. We propose that targeting these contact-independent immune-suppressive factors may complement current contact-dependent therapeutic strategies (checkpoint inhibitors) to boost anti-tumor immune cell function and thereby prevent or decrease TNBC metastasis.

Citation Format: Williams MM, Christenson JL, O'Neill K, Rogers TJ, Greene LI, Slansky J, Richer JK. Epithelial-mesenchymal transition promotes triple negative breast cancer immune suppression [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-01-04.

Mother and Home Visitor Emotional Well-Being and Alignment on Goals for Home Visiting as Factors for Program Engagement

Objectives Family engagement in home visiting (HV), as indicated by length of enrollment, is a major challenge as most families do not stay enrolled for the intended duration prescribed by HV models. This study examined maternal and visitor emotional well-being as factors for maternal satisfaction with the program in addressing reasons for enrolling in HV and program engagement and the role of their working alliance with the visitor as a mediator of this. Methods Longitudinal data were collected from 148 mothers and 54 visitors in 21 HV programs. Mothers completed surveys shortly after enrolling and 6 months later to assess attributes of the working alliance with their visitor. Visitors completed a survey to assess work-related well-being. HV program data were used to measure engagement. Results Mothers enrolled for multiple, diverse reasons, most often to promote child development and parenting (96%). Mothers’ satisfaction with program efforts to address reasons for enrollment was highest for parenting (79%) and lowest for jobs and education (30%). Results of the mediational path model indicated that ratings of the visitor on goal alignment were positively associated with engagement. Maternal emotional availability and visitor work-related emotional exhaustion were negatively associated with engagement. Exploratory analyses suggested that ratings of the visitor on goal alignment were a stronger predictor of engagement for mothers with low emotional availability compared to other mothers. Conclusions for Practice Visitor alignment with mothers on goals and responsiveness to reasons for enrolling appear to be effective in promoting engagement. Individualizing services to reflect maternal goals and emotional capacity may be important strategies to address engagement challenges.

Correction to: Mother and Home Visitor Emotional Well-Being and Alignment on Goals for Home Visiting as Factors for Program Engagement

The article "Mother and Home Visitor Emotional Well-Being and Alignment on Goals for Home Visiting as Factors for Program Engagement", written by L. Burrell, S. Crowne, K. Ojo, R. Snead, K. O'Neill, F. Cluxton‑Keller and A. Duggan, was originally published electronically on the publisher's internet portal (currently SpringerLink) on 31 May 2018 without open access.

Racial disparities in refusal of stroke thrombolysis in Chicago

OBJECTIVE

To evaluate race differences in tissue plasminogen activator (tPA) refusal among eligible patients with acute ischemic stroke (AIS) in Chicago.

METHODS

Using the Get With The Guidelines-Stroke registry data from 15 primary stroke centers between January 2013 and June 2015, we performed a retrospective analysis of patients with AIS presenting to the emergency department within 4.5 hours from symptom onset. Patient or proxy refusal was captured as a reason for nonadministration of tPA to eligible patients in the registry. We assessed whether tPA refusal differed by race using logistic regression.

RESULTS

Among 704 tPA-eligible patients with AIS, tPA was administered to 86.2% (black race, 82.5% vs nonblack race, 89.5%; p < 0.001). Fifty-three (7.5%) tPA refusals were documented. Refusal was more common in black vs nonblack patients (10.6% vs 4.8%; p = 0.004). In multivariable analysis, the following were associated with tPA refusal: black race (adjusted odds ratio [OR] 2.5, 95% confidence interval [CI] 1.3-4.6), self-pay status (adjusted OR 3.23, 95% CI 1.2-8.71), prior stroke (adjusted OR 2.11, 95% CI 1.14-3.90), age (adjusted OR 1.04, 95% CI 1.02-1.07), and NIH Stroke Scale score (adjusted OR 0.94, 95% CI 0.90-0.99).

CONCLUSIONS

Among tPA-eligible patients with AIS in Chicago, over 7% refused tPA. Refusal was more common in black patients and accounted for the apparent lower rates of tPA use in black vs nonblack patients. Further research is needed to understand barriers to consent and overcome race-ethnic disparities in tPA treatment for AIS.

Treating Problem Gambling Samples with Cognitive Behavioural Therapy and Mindfulness-Based Interventions: A Clinical Trial

The problem gambling (PG) intervention literature is characterised by a variety of psychological treatments and approaches, with varying levels of evidence (PGRTC in Guideline for screening, assessment and treatment in problem and pathological gambling. Monash University, Melbourne, 2011). A recent PG systematic review (Maynard et al. in Res Soc Work Pract, 2015. doi: 10.1177/1049731515606977 ) and the success of mindfulness-based interventions to effectively treat disorders commonly comorbid with PG suggested mindfulness-based interventions may be effective for treating PG. The current study tested the effectiveness of three interventions to treat PGs: 1. case formulation driven Cognitive Behaviour Therapy (CBT); 2. manualised CBT; and 3. mindfulness-based treatment. All three interventions tested returned large effect size improvements in PG behaviour after seven sessions (Cohen's d range 1.46-2.01), at post-treatment and at 3 and 6-month follow-up. All of the interventions were rated as acceptable by participants at post-treatment. This study suggests that the mindfulness-based and TAU interventions used in the current study appear to be effective at reducing PG behavior and associated distress and they also appear to generalise to improvements in other measures such as quality of life-mental functioning and certain mindfulness facets more effectively than the manualised form of CBT utilised used here. Secondly, a brief mindfulness intervention delivered after psycho-education and a brief CBT intervention may be a useful supplement to traditional CBT treatments by addressing transdiagnostic processes such as rumination and thought suppression. Thirdly, CBT interventions continue to report effectiveness in reducing PG behaviour and associated distress consistent with the prevailing literature and clinical direction.

Retrospective review of Surgical Availability and Readiness in 8 African countries

OBJECTIVES

The purpose of this study was to assess surgical availability and readiness in 8 African countries using the WHO's Service Availability and Readiness Assessment (SARA) tool.

SETTING

We analysed data for surgical services, including basic and comprehensive surgery, comprehensive obstetric care, blood transfusion, and infection prevention, obtained from the WHO's SARA surveys in Sierra Leone, Uganda, Mauritania, Benin, Zambia, Burkina Faso, Democratic Republic of Congo and Togo.

PRIMARY AND SECONDARY OUTCOME MEASURES

Among the facilities that were expected to offer surgical services (N=3492), there were wide disparities between the countries in the number of facilities per 100 000 population that reported offering basic surgery (1.0-12.1), comprehensive surgery (0.1-0.8), comprehensive obstetric care (0.1-0.8) and blood transfusion (0.1-0.8). Only 0.1-0.3 facilities per 100 000 population had all three bellwether procedures available, namely laparotomy, open fracture management and caesarean section. In all the countries, the facilities that reported offering surgical services generally had a shortage of the necessary items for offering the services and this varied greatly between the countries, with the facilities having on average 27-53% of the items necessary for offering basic surgery, 56-83% for comprehensive surgery, 49-72% for comprehensive obstetric care and 54-80% for blood transfusion. Furthermore, few facilities had all the necessary items present. However, facilities that reported offering surgical services had on average most of the necessary items for the prevention of infection.

CONCLUSIONS

There are important gaps in the surgical services in the 8 African countries surveyed. Efforts are therefore urgently needed to address deficiencies in the availability and readiness to deliver surgical services in these nations, and this will require commitment from multiple stakeholders. SARA may be used to monitor availability and readiness at regular intervals, which will enable stakeholders to evaluate progress and identify gaps and areas for improvement.

Regional Learning Collaboratives Produce Rapid and Sustainable Improvements in Stroke Thrombolysis Times

BACKGROUND

Reduction in door-to-needle (DTN) times in patients with acute ischemic stroke treated with tissue-type plasminogen activator is associated with improved outcomes. We hypothesized that a learning collaborative would rapidly reduce DTN times at Chicago's primary stroke centers.

METHODS AND RESULTS

We analyzed data from all adult patients with out-of-hospital ischemic stroke hospitalized between January 1, 2010 and March 31, 2015 and who received tissue-type plasminogen activator in the emergency department at 15 primary stroke centers in Chicago and 15 primary stroke centers in St. Louis. We implemented a structured learning collaborative in Chicago in quarter 1 of 2013 that included (1) a quality improvement leader, (2) stroke content expert, (3) multidisciplinary teams from each site, (4) a targeted goal for the program (DTN time <60 minutes in >50% of patients treated with tissue-type plasminogen activator), and (5) face-to-face meetings with on-site visits. We used interrupted time-series analysis to compare the impact of the learning collaborative on DTN times in Chicago pre- and post implementation and also concurrently versus St. Louis. We prespecified adjustment for mode of arrival, emergency medical services prenotification, and onset-to-arrival times. P values less than 0.05 were considered significant. In adjusted analysis, the reduction in DTN time within 1 quarter of implementation was 15.5 minutes (P=0.046) at Chicago sites versus 1.17 minutes at St. Louis sites (P=0.601).

CONCLUSIONS

Using a learning collaborative model at Chicago's 15 primary stroke centers, we observed major reductions in DTN times within 1 quarter of implementation. Regional collaboration and best practices sharing should be a model for rapid and sustainable system-wide quality improvement.

Are Atrial Fibrillation Guidelines Altering Management? A Community Based Study

Background and Aims: We wanted to determine the prevalence of atrial fibrillation (AF) in a community based cross sectional study in greater Glasgow and how current anti thrombotic management compares to published guidelines. Methods: 1466 patients with AF were identified in General Practices in our community and 1008 consented to take part. Their demographic details and medical history were recorded. Results: 1466 patients (mean age 73.4; 55% female) with AF were identified, in our community, giving a prevalence of 1%. 53% of patients were on warfarin therapy. Of those not receiving warfarin, only one third had a putative contra-indication. The proportion of AF patients on warfarin increased with increasing stroke risk, and over the period of the study. Conclusions: Prevalence of AF was in keeping with previous estimates. The proportion of patients with AF receiving warfarin therapy appears to be increasing. In the moderate risk group, there was a tendency to use more warfarin in the younger age groups compared to the elderly. It was in the moderate and low risk groups that there was still evidence of deviation from published guidelines.

Restoring motor control and sensory feedback in people with upper extremity amputations using arrays of 96 microelectrodes implanted in the median and ulnar nerves

OBJECTIVE

An important goal of neuroprosthetic research is to establish bidirectional communication between the user and new prosthetic limbs that are capable of controlling >20 different movements. One strategy for achieving this goal is to interface the prosthetic limb directly with efferent and afferent fibres in the peripheral nervous system using an array of intrafascicular microelectrodes. This approach would provide access to a large number of independent neural pathways for controlling high degree-of-freedom prosthetic limbs, as well as evoking multiple-complex sensory percepts.

APPROACH

Utah Slanted Electrode Arrays (USEAs, 96 recording/stimulating electrodes) were implanted for 30 days into the median (Subject 1-M, 31 years post-amputation) or ulnar (Subject 2-U, 1.5 years post-amputation) nerves of two amputees. Neural activity was recorded during intended movements of the subject's phantom fingers and a linear Kalman filter was used to decode the neural data. Microelectrode stimulation of varying amplitudes and frequencies was delivered via single or multiple electrodes to investigate the number, size and quality of sensory percepts that could be evoked. Device performance over time was assessed by measuring: electrode impedances, signal-to-noise ratios (SNRs), stimulation thresholds, number and stability of evoked percepts.

MAIN RESULTS

The subjects were able to proportionally, control individual fingers of a virtual robotic hand, with 13 different movements decoded offline (r = 0.48) and two movements decoded online. Electrical stimulation across one USEA evoked >80 sensory percepts. Varying the stimulation parameters modulated percept quality. Devices remained intrafascicularly implanted for the duration of the study with no significant changes in the SNRs or percept thresholds.

SIGNIFICANCE

This study demonstrated that an array of 96 microelectrodes can be implanted into the human peripheral nervous system for up to 1 month durations. Such an array could provide intuitive control of a virtual prosthetic hand with broad sensory feedback.

Density of GFAP-immunoreactive astrocytes is decreased in left hippocampi in major depressive disorder

Neuroimaging and postmortem studies of subjects with major depressive disorder (MDD) reveal smaller hippocampal volume with lengthening duration of illness. Pathology in astrocytes may contribute significantly to this reduced volume and to the involvement of the hippocampus in MDD. Postmortem hippocampal tissues were collected from 17 subjects with MDD and 17 psychiatrically-normal control subjects. Sections from the body of the hippocampus were immunostained for glial fibrillary acidic protein (GFAP), a marker of intermediate filament protein expressed in astrocytes. The density of GFAP-immunoreactive astrocytes was measured in the hippocampus using 3-dimensional cell counting. Hippocampal subfields were also assessed for GFAP-immunoreactive area fraction. In CA1, there was a significant positive correlation between age and either density or area fraction in MDD. The density of astrocytes in the hilus, but not CA1 or CA2/3, was significantly decreased only in depressed subjects not taking an antidepressant drug, but not for depressed subjects taking an antidepressant drug. The area fraction of GFAP-immunoreactivity was significantly decreased in the dentate gyrus in women but not men with depression. In CA2/3, the area fraction of GFAP-immunoreactivity was inversely correlated with the duration of depression in suicide victims. Astrocyte contributions to neuronal function in the hilus may be compromised in depressed subjects not taking antidepressant medication. Due to the cross-sectional nature of the present study of postmortem brain tissue, it remains to be determined whether antidepressant drug treatment prevented a decrease in GFAP-immunoreactive astrocyte density or restored cell density to normal levels.

Reference sequence (RefSeq) database at NCBI: current status, taxonomic expansion, and functional annotation

The RefSeq project at the National Center for Biotechnology Information (NCBI) maintains and curates a publicly available database of annotated genomic, transcript, and protein sequence records (http://www.ncbi.nlm.nih.gov/refseq/). The RefSeq project leverages the data submitted to the International Nucleotide Sequence Database Collaboration (INSDC) against a combination of computation, manual curation, and collaboration to produce a standard set of stable, non-redundant reference sequences. The RefSeq project augments these reference sequences with current knowledge including publications, functional features and informative nomenclature. The database currently represents sequences from more than 55,000 organisms (>4800 viruses, >40,000 prokaryotes and >10,000 eukaryotes; RefSeq release 71), ranging from a single record to complete genomes. This paper summarizes the current status of the viral, prokaryotic, and eukaryotic branches of the RefSeq project, reports on improvements to data access and details efforts to further expand the taxonomic representation of the collection. We also highlight diverse functional curation initiatives that support multiple uses of RefSeq data including taxonomic validation, genome annotation, comparative genomics, and clinical testing. We summarize our approach to utilizing available RNA-Seq and other data types in our manual curation process for vertebrate, plant, and other species, and describe a new direction for prokaryotic genomes and protein name management.

Catastrophic expenditure to pay for surgery worldwide: a modelling study

BACKGROUND

Approximately 150 million individuals worldwide face catastrophic expenditure each year from medical costs alone, and the non-medical costs of accessing care increase that number. The proportion of this expenditure related to surgery is unknown. Because the World Bank has proposed elimination of medical impoverishment by 2030, the effect of surgical conditions on financial catastrophe should be quantified so that any financial risk protection mechanisms can appropriately incorporate surgery.

METHODS

To estimate the global incidence of catastrophic expenditure due to surgery, we built a stochastic model. The income distribution of each country, the probability of requiring surgery, and the medical and non-medical costs faced for surgery were incorporated. Sensitivity analyses were run to test the robustness of the model.

FINDINGS

3·7 billion people (posterior credible interval 3·2-4·2 billion) risk catastrophic expenditure if they need surgery. Each year, 81·3 million people (80·8-81·7 million) worldwide are driven to financial catastrophe-32·8 million (32·4-33·1 million) from the costs of surgery alone and 48·5 million (47·7-49·3) from associated non-medical costs. The burden of catastrophic expenditure is highest in countries of low and middle income; within any country, it falls on the poor. Estimates were sensitive to the definition of catastrophic expenditure and the costs of care. The inequitable burden distribution was robust to model assumptions.

INTERPRETATION

Half the global population is at risk of financial catastrophe from surgery. Each year, surgical conditions cause 81 million individuals to face catastrophic expenditure, of which less than half is attributable to medical costs. These findings highlight the need for financial risk protection for surgery in health-system design.

FUNDING

MGS received partial funding from NIH/NCI R25CA92203.

A time-driven activity-based costing model to improve health-care resource use in Mirebalais, Haiti

BACKGROUND

In resource-limited settings, efficiency is crucial to maximise resources available for patient care. Time driven activity-based costing (TDABC) estimates costs directly from clinical and administrative processes used in patient care, thereby providing valuable information for process improvements. TDABC is more accurate and simpler than traditional activity-based costing because it assigns resource costs to patients based on the amount of time clinical and staff resources are used in patient encounters. Other costing approaches use somewhat arbitrary allocations that provide little transparency into the actual clinical processes used to treat medical conditions. TDABC has been successfully applied in European and US health-care settings to facilitate process improvements and new reimbursement approaches, but it has not been used in resource-limited settings. We aimed to optimise TDABC for use in a resource-limited setting to provide accurate procedure and service costs, reliably predict financing needs, inform quality improvement initiatives, and maximise efficiency.

METHODS

A multidisciplinary team used TDABC to map clinical processes for obstetric care (vaginal and caesarean deliveries, from triage to post-partum discharge) and breast cancer care (diagnosis, chemotherapy, surgery, and support services, such as pharmacy, radiology, laboratory, and counselling) at Hôpital Universitaire de Mirebalais (HUM) in Haiti. The team estimated the direct costs of personnel, equipment, and facilities used in patient care based on the amount of time each of these resources was used. We calculated inpatient personnel costs by allocating provider costs per staffed bed, and assigned indirect costs (administration, facility maintenance and operations, education, procurement and warehouse, bloodbank, and morgue) to various subgroups of the patient population. This study was approved by the Partners in Health/Zanmi Lasante Research Committee.

FINDINGS

The direct cost of an uncomplicated vaginal delivery at HUM was US$62 and the direct cost of a caesarean delivery was US$249. The direct costs of breast cancer care (including diagnostics, chemotherapy, and mastectomy) totalled US$1393. A mastectomy, including post-anaesthesia recovery and inpatient stay, totalled US$282 in direct costs. Indirect costs comprised 26-38% of total costs, and salaries were the largest percentage of total costs (51-72%).

INTERPRETATION

Accurate costing of health services is vital for financial officers and funders. TDABC showed opportunities at HUM to optimise use of resources and reduce costs-for instance, by streamlining sterilisation procedures and redistributing certain tasks to improve teamwork. TDABC has also improved budget forecasting and informed financing decisions. HUM leadership recognised its value to improve health-care delivery and expand access in low-resource settings.

FUNDING

Boston Children's Hospital, Harvard Business School, and Partners in Health.