The Development of Diabetes and Diabetic Ketoacidosis Following Immunotherapy Treatment: A Systematic Review of Case Reports

As cancer continues to be the leading cause of death worldwide, additional therapeutic options other than traditional platinum-based chemotherapy have become available that target tumor cells in innovative ways. Immunotherapies (e.g., immune checkpoint inhibitors (ICI)) ramp up the immune system to target cancer cells, providing patients with more personalized and tumor cell-specific treatment options. This new age oncological treatment option has been found to provide a more meaningful and stronger alternative to traditional chemotherapy, resulting in longer periods of remission and milder side effects. However, because ICI heightens the immune system, resultant autoimmune conditions can occur. One of the most recently shown adverse effects of ICI are extreme hyperglycemia (i.e., type 1 diabetes) and diabetic ketoacidosis (DKA). To determine the incidence of immunotherapy-induced diabetes, a systematic literature review was performed using CINHAL, EBSCO, MEDLINE, and Web of Science. A total of 403 articles were initially screened, with a final 28 case reports included. The results show that checkpoint inhibitors were found to be most commonly associated with new-onset diabetes as opposed to traditional chemotherapy. Additionally, 41% of patients developed autoimmune diabetes and DKA after being placed on a single therapy of pembrolizumab (targets PD-1: programmed cell death protein 1). However, the pathological process underlying the development of endocrinopathies after treatment with ICI continues to be under investigation.

The role of aspirin, statins, colchicine, and IL-1 inhibitors in prevention of cardiovascular events: a systematic integrative review

CONTEXT

Cardiovascular disease (CVD) is the leading cause of death in the United States. As such, an unmet need exists in the primary and secondary prevention of adverse cardiovascular events (CVEs). Specifically, identifying drugs that can reduce the progression of CVD and serious adverse events is much needed. Drugs that work by reducing platelet aggregation, blocking cholesterol formation (3-hydroxy-3-methyl-glutaryl-coenzyme A [HMG-CoA] reductase inhibitors), and/or blocking inflammation pathways (mainly interleukin-1b [IL-1b]) have been linked to preventing adverse CVEs, including acetylsalicylic acid (ASA, aspirin), statins, colchicine, and IL-1 inhibitors (interleukin-1 receptor antagonists). This systematic review aims to provide insight into utilizing these four agents for the primary and/or secondary prevention of CVD.

OBJECTIVES

In this systematic review, we opted to review the efficacy of aspirin, statins, colchicine, and IL-1 inhibitors in the primary and secondary prevention of CVE to provide clinical practitioners with evidence-based practice approaches and determine any unmet needs in their utilization.

METHODS

Between October 1 and 12, 2021, a search was conducted and completed on five databases: PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, and Biomedical Reference Collection: Comprehensive. A total of 13 researchers (V.A., A.H., S.B., V.G., D.C., C.C., C.B., C.A., S.K., J.H., A.K., S.F., and S.E.) were involved in the search and screening of the articles. Search terms included "aspirin, statins, colchicine, IL-1 inhibitors, and primary, secondary, myocardial infarction (MI)." Inclusion criteria included clinical study design, English language articles, all genders older than 50 years old, and established patient history of CVD, including MI. In addition, articles were excluded if they were animal models, in vitro studies, pharmacokinetic studies, systematic reviews, literature reviews, and studies exploring therapies other than those listed in the inclusion criteria. First, five individuals independently sorted through abstracts or articles based on the inclusion and exclusion criteria. Then, a team of 13 individuals sorted through full-text articles of selected abstracts based on the same criteria. A separate researcher resolved conflicts between the team.

RESULTS

A total of 725 articles were identified from all databases, from which 256 duplicated articles were removed. Thus, a total of 469 articles abstracts were screened, of which 425 articles either did not meet the inclusion criteria or met the exclusion criteria. A total of 42 articles were retrieved and assessed for full-text review, from which 15 articles were retrieved for analysis.

CONCLUSIONS

Statins may prevent primary CVEs based on their role in preventing cholesterol formation. Aspirin, canakinumab, and colchicine may be helpful in the secondary prevention of CVEs due to their blocking of various steps in the inflammation pathway leading to CVD. Future research should primarily focus on the use of canakinumab and colchicine in preventing CVD due to the limited number of studies on these drugs.

Co-occurrence of glioma and multiple sclerosis: Prevailing theories and emerging therapies

Though the concurrence of primary brain tumors and multiple sclerosis (MS) is exceedingly rare, instances have been noted in the literature as early as 1949. Given these observations, researchers have proposed various ideas as to how these malignancies may be linked to MS. Due to insufficient data, none have gained traction or been widely accepted amongst neurologists or neuro-oncologists. What is abundantly clear, however, is the mounting uncertainty faced by clinicians when caring for these individuals. Concerns persist about the potential for disease modifying therapies (DMTs) to initiate or promote tumor growth and progression, and to date, there are no approved treatments capable of mitigating both MS disease activity and tumor growth, let alone established guidelines that clinicians may refer to. Collectively, these gaps in the literature impose limitations to optimizing the care and management of this population. As such, our hope is to stimulate further discussion of this topic and prompt future investigations to explore novel treatment options and advance our understanding of these concurrent disease processes. To this end, the chief objective of this article is to evaluate proposed ideas of how the diseases may be linked, outline emerging therapies for both MS and brain tumors, and describe evidence-based approaches to diagnosing and treating this patient population.

Radiation-Induced Peripheral Artery Disease in a 63-Year-Old Patient

Tobacco use, hypertension, diabetes, and hypercholesterolemia are known risk factors for peripheral artery disease (PAD). However, additional causes of PAD, such as radiation therapy, should be considered for the prevention and diagnosis of this disease. The patient described in this report had 36 radiation therapies directly to the pelvis and bladder area due to bladder cancer. The presence of severe PAD on this patient's right external iliac artery, the same area where he received radiation therapy, raises the question of whether radiation therapy contributed to the development of PAD. In addition, his history of anal intraepithelial neoplasia, obstructive uropathy, and chronic kidney disease further demonstrated that he possibly suffered extensive tissue damage due to radiation to the pelvis. This case report explores the current diagnosis guidelines and treatment options for patients with radiation-induced PAD. Through this case study, we aim to bring awareness to this lesser-known cause of PAD among medical providers and promote research for the prevention and treatment of this disease.

Computed Tomography (CT) Calcium Scoring in Primary Prevention of Acute Coronary Syndrome and Future Cardiac Events in Patients With Systemic Lupus Erythematosus

Systemic lupus erythematosus (SLE) is a complex and chronic autoimmune disease that impacts multiple organ systems and presents with varying symptomatology that makes targeting treatment extremely difficult. The cardiovascular system and more specifically the coronary arteries are heavily affected by SLE causing increased atherosclerosis and subsequently increased acute coronary syndrome (ACS) and increased future cardiac events. ACS is a common occurrence in patients with SLE due to the premature development of atherosclerosis due to the dysregulation of pro-inflammatory cytokines. Calcium scoring has been effectively utilized to identify plaque burden in patients with coronary artery calcification (CAC). Calcium scoring is a score obtained from a computed tomography (CT) image using non-contrast imaging, which provides quantitative information regarding CAC and aids in assessing cardiovascular risk. A calcium score of zero Hounsfeild units can be obtained using CT calcium scoring which indicates no calcium is identified in the coronary arteries and is a strong negative risk predictor for coronary artery disease. Early screening of SLE patients with CT calcium scoring could aid in early detection and treatment subsequently leading to delay of premature coronary atherosclerosis and future cardiac events in this patient population. Multiple studies have used calcium scoring as a method to measure arterial calcification in SLE patients. The Society of Cardiovascular Imaging has now endorsed the idea of obtaining a baseline calcium artery score with a repeat progression scan in 3-5 years. Calcium scoring has also been identified as an effective initial tool for stratification and identification of possible ACS. The various advantages of early calcium scoring signify the further research needed to fully understand and implement the advantages calcium scoring has to offer patients with SLE.

The Impact of Modern Dietary Practices on Cancer Risk and Progression: A Systematic Review

Cancer is a leading cause of mortality around the world, despite continued advancements in the management of cancer. Recent research efforts have shifted to evaluating the role that modifiable risk factors play in cancer risk and development, as diet and nutrition have been found to play a significant role in the onset and progression of cancer. As a result, there has been an increasing focus on the impact of dietary modifications on preventing the onset, progression, and reoccurrence of cancer. In this systematic review, data were collected on three common diets, the Mediterranean diet (MD), ketogenic diet (KD), and plant-based diet, to gain insight into the application of these three dietary modification approaches for risk prevention and limitation of cancer burden. Initially, 4,397 articles were identified from three databases (Ovid, Web of Science, and CINHAL). After removing studies based on the exclusion criteria, only 23 studies were eligible to be included in the systematic review of which 15 evaluated the MD, four assessed the ketogenic diet, and four evaluated the plant-based diet. Each article was considered for its methods, procedures, and findings. The findings indicate that dietary interventions may effectively reduce the odds of cancer development and the advancement of diagnosed cancers. With the introduction of the MD, KD, and plant-based diets, significant improvements in lowering cancer development, recurrence-free status, and limiting tumor growth were noted across numerous cancer types. Currently, the MD has been extensively studied in the literature, and amongst the widest variety of cancer types. Additional information and evaluation are required on the ketogenic and plant-based diets to fully understand their impact on the cancer burden across a wider subset of cancers. Clinicians should evaluate and recommend nutritional adaptations to their patients to limit the development of specific cancers and as an adjunctive therapy to traditional pharmacological treatment options for patients with diagnosed cancers.

Paradoxical Tumor Necrosis Factor-Alpha (TNF-α) Inhibitor-Induced Psoriasis: A Systematic Review of Pathogenesis, Clinical Presentation, and Treatment

Tumor necrosis factor-alpha (TNF-α) inhibitors have been shown to be well tolerated among patients with rheumatoid arthritis, inflammatory bowel disease, and psoriasis. Meanwhile, more recently, clinical practice and research efforts have uncovered increasing cases of psoriatic lesion development tied to initiating treatment with a TNF-α inhibitor. The underlying mechanisms associated with this occurrence have yet to be fully elucidated. A review and analysis of cases of paradoxical psoriasis currently published in the literature is warranted. In addition, exploring possible mechanisms of action and potential treatment options associated with favorable outcomes is much needed. A systematic literature review was performed utilizing PubMed and Google Scholar databases (1992-present), in which 106 cases of paradoxical psoriasis were reviewed. The most common morphology developed was plaque psoriasis vulgaris. There was a female predominance (61.3%), and the most common underlying autoimmune disease was rheumatoid arthritis (45.3%). In addition, the most commonly associated drug with the onset of psoriatic lesions was infliximab (62.3%). Furthermore, the findings suggest that the most well-supported mechanism of action involves the uncontrolled release of interferon-alpha (IFN-α) from plasmacytoid dendritic cells (pDCs) after TNF-α inhibition. While TNF-α inhibitors have been shown to have great benefits to patients with rheumatologic diseases, cases of paradoxical psoriasis demonstrate the importance of close monitoring of patients on TNF-α inhibitors to allow for early recognition, treatment, and potentially change to a different mechanism of action of the medication used to prevent further progression of the inflammatory lesions.

Correction: Surgical Versus Non-Surgical Treatments for the Knee: Which Is More Effective?

[This corrects the article DOI: 10.7759/cureus.34860.].

Glucocorticoid use in rheumatoid arthritis patients and the onset of pneumonia: a systematic review and meta-analysis

CONTEXT

Rheumatoid arthritis (RA) is a systemic autoimmune disease that commonly affects joints. Although many treatment options exist, the most common, disease-modifying antirheumatic drugs (DMARDs), have been associated with pulmonary infections. These types of infections (specifically pneumonia) can be detrimental to RA patients. This leads providers to utilize other treatment modalities such as glucocorticoids (GCs). GCs are commonly utilized to treat RA; however, the role of GCs in the onset of pneumonia in RA patients is not fully understood.

OBJECTIVES

The goal of this study was to systematically review and statistically analyze pooled data documenting pneumonia as an adverse event in RA patients on DMARDs as a monotherapy vs RA patients on DMARDs and GCs as combination therapy utilizing the Population, Intervention, Comparison, and Outcomes (PICO) framework.

METHODS

On August 1, 2021, a search was conducted and completed on six databases: Embase, MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, International Pharmaceutical Abstracts (IPA), and ClinicalTrials.gov. A total of 12 researchers were involved with the search and screening of articles (K.E., P.R.; V.A., D.P.C.; C.B., D.C.; T.A., E.S.; S.H., L.B.; K.S., C.S.). Search terms were identified utilizing Medical Subject Headings (MeSH) and Emtree and included "glucocorticoids," "rheumatoid arthritis," "pneumonia," and "respiratory tract infections," Inclusion criteria included human subjects over the age of 18 with seropositive RA, on a combination of GC (prednisone, methylprednisolone, or prednisolone) with DMARD (methotrexate [MTX], hydroxychloroquine [HCQ], or sulfasalazine [SSZ]) and developed pneumonia of bacterial, viral, or fungal origin. The control groups were on a DMARD monotherapy regimen. Articles were excluded if they were not in English, had less than 20 participants, were case reports or literature reviews, included animal subjects, and did not adhere to the established PICO framework. Five teams of two researchers individually sorted through abstracts of articles based on the inclusion and exclusion criteria. The same teams individually sorted through full-text articles of selected abstracts based on the same criteria. Conflicts between each team were resolved by a separate researcher. Odds ratios were utilized to quantify the effect sizes of combined studies from a random effects model. Chi-square tests and I2 statistics were utilized to analyze heterogeneity.

RESULTS

A total of 3360 articles were identified from all databases, and 416 duplicate articles were removed. Thus, a total of 2944 articles abstracts were screened, of which 2819 articles either did not meet the inclusion criteria or did meet the exclusion criteria. A total of 125 articles were retrieved and assessed for full-text eligibility, of which only three observational articles were included for meta-analysis. Statistical results revealed that patients treated with DMARDs monotherapy are 95% (95% CI: 0.65-0.99) less likely to develop pneumonia compared to patients treated with a DMARD and GCs (p=0.002).

CONCLUSIONS

Our data suggest that RA patients have a higher probability of developing pneumonia on combination therapy with GCs, compared to monotherapy with DMARDs. To our knowledge, our findings are the first to systematically review and statistically evaluate the relationship between the use of GCs and show an increased chance of developing pneumonia.

The Overlap of Diabetes and Osteoarthritis in American Populations

Diabetes mellitus, a condition in which the body's ability to produce insulin is impaired, and osteoarthritis (OA), a painful degeneration of joint cartilage, are both serious conditions that affect millions of people in the United States (U.S.). Osteoarthritis is a chronic degenerative condition of the joint cartilage, affecting mainly the older population. The purpose of this paper is to find a connection, if any, between diabetes and osteoarthritis and if either condition can predispose an individual to the other. Not only can this review help to explain the co-existence of these two diseases, but it can also be used to look into a cure for patients in the future. After preliminary searches were done on PubMed, results were narrowed using specific keywords and similar risk factors among the two diseases. It was found that these two conditions are actually interrelated due to oxidative stress and pro-inflammatory cytokines. Seeing the high risk of developing one of these conditions and that obesity, one of the biggest risk factors for both diabetes and osteoarthritis, is at an all-time high in this country, a possible connection between the two of these diseases is very prevalent to look into. This information can be used to help correlate not only a better-targeted treatment but also lead to future research into why obesity is one of the biggest risk factors for both conditions.

Oral Microbiome as a Tool of Systemic Disease on Cleft Patients: A New Landscape

The oral cavity microbiome comprises benign and pathogenic bacteria, with more than 700 species identified. However, the current literature regarding resident bacterial flora in the oropharyngeal cavities in cleft lip/palate (CLP) patients still needs to be completed. This review aims to evaluate the role of the oral microbiome of cleft patients as an indicator in systemic diseases for which cleft patients might be at higher risk in the short or long term. A literature review was performed in July 2020 using Biomedical Reference Collection Comprehensive, Cumulative Index to Nursing and Allied Health Literature (CINAHL) Complete, Dentistry & Oral Sciences Source via Elton B. Stephens Company/Online Database (EBSCO), Turning Research into Practice (TRIP), and PubMed. The keywords used were "oral, bacteria, microbiome, biota, flora, cleft, palate." The resulting 466 articles were deduplicated using Endnote. The total amount of articles' abstracts without duplicates was filtered using a set criterion. The title and abstract filter criteria included 1) cleft lip (CL) and/or cleft palate (CP) patients, 2) changes in the oral microbiome in CL and/or CP patients, 3) male and female patients 0-21 years old, and 4) English language. The full-text filter criteria included 1) CL and/or CP patients vs. non-cleft control patients, 2) oral bacteria, 3) nonprocedural measurements of microorganisms, and 4) case-control studies. A Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) flow chart was created using the EndNote data results. The final five articles of the systematic search indicated that the oral cavity of cleft lip and/or palate patients resulted in 1) contradicting levels of Streptococcus mitis and Streptococcus salivarius; 2) lower levels of Streptococcus gordonii, Bordetella dentium, Fusobacterium nucleatum, Veillonella parvula, Bacillus and Lautropia when compared to the control group; 3) higher levels of Staphylococcus epidermidis and Methicillin-sensitive Staphylococcus aureus compared to the control group; 4) presence of Enterobacter cloacae 36.6%, Klebsiella pneumoni 53.3%, and Klebsiella oxytoca 76.6% vs. absence in the control non-cleft group. Patients with CL and/or CP are at higher risk for caries, periodontal diseases, and upper and lower respiratory infections. The results from this review indicate that relative levels of certain bacteria may be associated with these issues. The lower levels of S. mitis, S. salivarius, S. gordini, and F. nucleatum in the oral cavity of cleft patients could be linked as a possible cause of the higher incidence of tooth decay, gingivitis and periodontal disease as high levels of these bacteria are associated with oral disease. Further, the higher incidence of sinusitis in cleft patients might be linked to low levels of S. salivarius in the oral profile of these patients. Likewise, E. cloacae, K. oxycota, and K. pneumoni have been linked with pneumonia and bronchiolitis, both of which are increased in cleft patients. The oral bacterial dysbiosis of cleft patients observed in this review may play a vital function in the oral microbiome's diversity, which could play a role in disease progression and disease markers. The pattern seen in cleft patients potentially demonstrates how structural abnormalities can lead to the onset of severe infection.

Surgical Versus Non-Surgical Treatments for the Knee: Which Is More Effective?

Osteoarthritis is a degenerative joint disease that is extremely prevalent in society. It affects more than 25% of Americans above the age of 18 years. According to July 2020 publication by the Centers for Disease Control (CDC), osteoarthritis affects approximately 325 million Americans. One of the organs that is most affected by osteoarthritis is the knee. Over the years, we have developed non-surgical treatments, such as physical therapy (PT) and injections, and surgical treatments, such as total knee arthroplasty (TKA) and arthroscopic lavage, for knee osteoarthritis (KOA). If a patient fails with non-surgical options, which are tried first to avoid the risks of surgery, the patient may be considered for knee surgery. This article will investigate the different non-surgical options and TKA as treatment options for KOA based on current literature. The goal of this paper is to be a comprehensive resource for physicians and patients with KOA to make an informed decision. A systematic literature search was conducted using PubMed. The search terms were based on the type of treatments for KOA. To find articles that compared TKA to non-surgical treatments, the terms included "osteoarthritis", "total knee", and "non-surgical treatments," in combination. For other non-surgical treatments such as PT, weight reduction, and injections, a combination of the treatment, "osteoarthritis", and "knee" were included in the search. For the tier 1 process, any randomized controlled trials were included. Any case reports, observational studies, and cross-sectional studies were eliminated from the search. For the tier 2 review process, any articles that did not have relevance to the topic were eliminated after reading the abstracts of the articles. After review of the literature, the data seem to suggest that TKA with 12 weeks of non-surgical treatment improved pain and functionality of the knee more than just 12 weeks of non-surgical treatment when followed up at 12 and 24 months. However, non-surgical treatment before TKA delays the need for surgery. Supervised PT, either in a group or individual format, has been shown to delay TKA in 95% patients in the group that received PT at the end of one year. In addition, weight reduction has been shown as an effective strategy to improve pain and functionality in KOA patients, which decreases the urgency for surgery. Furthermore, platelet-rich plasma (PRP) injections have been shown to have long-term symptomatic relief for KOA compared to hyaluronic acid (HA) and corticosteroid injections. However, HA and corticosteroid injections are beneficial in treating KOA more than receiving no treatment. Physicians often have difficulty deciding whether to pursue conservative or surgical treatment for patients with KOA. The non-surgical treatments explored in this review - PT, injections, and weight reduction - can provide symptomatic relief and, in some cases, delay the need for surgical intervention. However, based on some randomized clinical trials mentioned in the article, patients receiving TKA have more relief, better quality of life, and improved functionality compared to non-surgical therapy. However, a critical review of this important field of debate shows that there are limited randomized controlled studies comparing the effectiveness of TKA and non-surgical treatments for KOA. We believe that this controversial topic needs further clinical investigation.

WITHDRAWN: Vaccination of multiple sclerosis patients during the COVID-19 era: Novel insights into vaccine safety and immunogenicity

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Vaccination of multiple sclerosis patients during the COVID-19 era: Novel insights into vaccine safety and immunogenicity

Multiple sclerosis (MS) is an incurable autoimmune disease known to cause widespread demyelinating lesions in the central nervous system (CNS) and a host of debilitating symptoms in patients. The development of MS is believed to be driven by the breakdown of the blood brain barrier, subsequent infiltration by CD4⁺ and CD8⁺ T cells, and widespread CNS inflammation and demyelination. Disease modifying therapies (DMTs) profoundly disrupt these processes and therefore compose an essential component of disease management. However, the effects of these therapeutic agents on vaccine safety and immunogenicity in individuals with MS are not yet fully understood. As such, the primary objective of this review article was to summarize the findings of recently conducted studies on vaccine safety and immunogenicity in MS patients treated with DMTs, particularly in the context of the ongoing coronavirus disease 2019 (COVID-19) pandemic. Discussed in this review are vaccinations against influenza, yellow fever, human papillomavirus, measles, mumps, rubella, Streptococcus pneumoniae, hepatitis B, and COVID-19. This article additionally reviews our current understanding of COVID-19 severity and incidence in this patient population, the risks and benefits of vaccination against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and vaccination guidelines set forth by MS societies and organizations.

Photodynamic Therapy Using Intense Pulse Light to Treat an HIV Patient With Perianal Squamous Cell Carcinoma: A Case Report

Anogenital warts are considered one of the most common sexually transmitted infections caused by the human papillomavirus (HPV). One of the primary considerations with HPV is the virus’s high rate to develop into squamous cell carcinoma (SCC). SCC is one of the leading causes of skin cancer with a variety of treatment options. The gold standard of treatment for SCC is surgical excision. Complications may arise for those that are considered immunocompromised, or lack of efficacy may be taken into consideration for nonsurgical approaches. Herein, we suggest prompt diagnosis and treatment with photodynamic therapy (PDT) of HPV lesions to prevent disease progression and reoccurrence.

The patient is a 54-year-old male nonsmoker with a past medical history of squamous cell carcinoma and HIV and presented with a perianal rash. Additionally, he confirmed associated symptoms of itchiness, irritation, and pain. At the time of his appointment, his CD4 count was 121 cells/µL, and he stated he was compliant with his antiretroviral therapy. Based on history and physical examination, the patient was empirically treated with oral fluconazole and topical nystatin-triamcinolone for two weeks. At follow-up, symptomatology worsened, and a biopsy was performed. Squamous cell carcinoma in situ was confirmed histologically. A secondary bacterial skin infection developed at the biopsy site. At this point, PDT was recommended due to compromised tissue and further risk of infection.

At present, a gold standard of care for HPV infection does not exist. Prompt diagnosis and treatment of these lesions are important to recognize due to the high risk of the development of squamous cell carcinoma. Complications of secondary bacterial infections can arise with current treatment for squamous cell carcinoma, particularly in the immunocompromised. Non-surgical approaches for HPV have been less than desirable with higher recurrence rates of HPV lesions. Herein, we suggest the consideration of PDT treatment for HPV and SCC.

Underlying Immune Mechanisms Involved in Cow’s Milk-Induced Hypersensitivity Reactions Manifesting as Atopic Dermatitis

Of the many symptoms associated with cow’s milk allergy (CMA), many populations face the burden of the appearance or worsening of atopic dermatitis (AD) when consuming milk products. Due to the prevalence and possible severity of symptoms, it is important to understand the underlying immune mechanisms involved in such reactions. Hypersensitivity reactions are exaggerated immune responses to often benign antigens, many times resulting in a cascade of pro-inflammatory processes. Of the four major types, type I and IV are of most relevance when considering atopic dermatitis worsened by cow’s milk. Considered a “true allergy,” type I (immediate) hypersensitivity reactions occur within hours after secondary exposure to an allergen and are primarily driven by antibodies and humoral immune responses. On the contrary, type IV (delayed) hypersensitivity reactions are driven by cell-mediated responses involving T-cell activation. Due to the array of symptoms induced by these complex reactions, it is imperative to diagnose early and treat appropriately. In this literature review, we aim to highlight the primary underlying immune contributors to hypersensitivity reactions, discuss AD as a manifestation of hypersensitivity reactions to cow’s milk, and consider current and future treatment options for combatting hypersensitivities manifesting as AD.

Psychoactive Drugs in the Management of Post Traumatic Stress Disorder: A Promising New Horizon

Post-traumatic stress disorder (PTSD) is an anxiety disorder that often presents after exposure to a traumatic, life-threatening event. Experiencing a traumatic event is not rare, with inciting incidents ranging from being burglarized to politically motivated genocide. While traditional psychopharmacology and psychotherapy are the mainstays of the treatment of PTSD currently, psychoactive drugs (otherwise known as psychedelics) are being explored for their novel role in the treatment of PTSD patients. Psychoactive drugs such as MDMA, ketamine, and psilocybin have been shown to specifically target and decrease fear and anxiety pathways in the brain. These unique properties hold the potential to be utilized in addressing symptoms of trauma in those with refractory or treatment-resistant PTSD. Historically, federal and state laws have restricted research into how psychoactive drugs can be used to treat mental illness due to the widespread belief that these drugs present more harm than benefit. However, the current shift in public opinion on psychedelics has propelled research to look into the benefits of these drugs for patients with mental illness. This article aims to discuss the mechanisms of how MDMA, ketamine, and psilocybin work in the PTSD brain, as well as their beneficial role in treatment.

Comorbidities and Symptomatology of SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2)-Related Myocarditis and SARS-CoV-2 Vaccine-Related Myocarditis: A Review

Myocarditis is an inflammatory disease of the heart muscle, with manifestations that include myocardial infarction, arrhythmia, and even sudden death. The primary etiology of myocarditis is a viral infection, with studies demonstrating that infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can lead to myocarditis. This enzyme is involved in many body tissues, including the gastrointestinal system and the cardiac system. This enzyme is responsible for converting angiotensin I to angiotensin II in the renin-angiotensin system of our body. This review aims to characterize the symptomatology and comorbidities of males, females, and pediatric patients who developed the SARS-CoV-2-related myocarditis (SARS-CoV-2RM) or the SARS-CoV-2 vaccine-related myocarditis (SARS-CoV-2VRM). From July 10 to July 20, 2021, a PubMed database search for “SARS CoV-2 Related Myocarditis” was conducted. From July 21 to July 30, 2021, the search for “SARS CoV-2 Vaccine Related Myocarditis” was conducted. The search completed was specific for title/abstract fields using keywords “Covid-19” AND “Myocarditis” AND “Vaccine” and specifying “Males” or “Females”, respectively. Inclusion criteria included articles discussing comorbidities and symptomatology. Exclusion criteria included autopsy/postmortem reports, letters to the editor, retrospective studies, and observational studies. In the end, 49 articles were found and included in this review. We found that 27 of 40 pediatric patients with SARS-CoV-2RM presented with gastrointestinal symptoms, and 12 of 40 pediatric patients had no comorbidities. In female cases, eight of 12 patients with SARS-CoV-2RM presented with noncardiac symptoms, and only four of 12 had comorbidities such as asthma, diabetes, and obesity. In male patients with SARS-CoV-2RM, 10 of 12 presented with respiratory and/or cardiac symptoms, and seven of 12 had cardiac and/or diabetic comorbidities. Furthermore, 22 of 31 male patients with SARS-CoV-2VRM presented with chest pain with no previous comorbidities; four of six females with SARS-CoV-2VRM presented with chest pain, and three of six females had no comorbidities; and seven of 11 pediatric patients with SARS-CoV-2VRM had no comorbidities, but 11 of 11 pediatric patients presented with chest pain. In conclusion, males, females, and pediatric patients with previous SARS-CoV-2VRM showed mostly chest pain with no comorbidities. Males presenting with SARS-CoV-2RM showed mostly respiratory and cardiac symptoms with cardiac and diabetic comorbidities. Females with SARS-CoV-2RM described various symptoms from flu-like, respiratory, to cardiac and had no previous comorbidities. The bulk of pediatric patients with SARS-CoV-2RM mainly presented with GI symptoms and no past comorbidities. More studies are needed to determine the clinical presentation and risk factors that lead to SARS-CoV-2RM and SARS-CoV-2VRM.

Immune-Mediated Renal Diseases: A Team-Based Learning Module for Preclinical Medical Students

INTRODUCTION

The underlying immune mechanisms of renal diseases are complex, and medical students benefit from learning these complexities in the setting of team-based learning (TBL), where they can apply foundational immunologic concepts to clinical problems.

METHODS

This immune-mediated renal disease TBL module focusing on glomerular disease was delivered over a period of 2 consecutive years in an integrated cardiovascular, pulmonary, and renal block within the second semester of the first year of medical school. Each class consisted of 53 students, for a total of 106 students. The TBL module consisted of a seven-question individual and team readiness assurance test (iRAT and tRAT) and two clinically relevant team application activities. Following the TBL module, students completed an 18-item survey that collected information on student perspectives of engagement.

RESULTS

For the 2-year period, the iRAT average scores were 73% and 74%, and the tRAT average scores were 100% and 99%, respectively. The survey assessing student perceptions of engagement yielded positive feedback.

DISCUSSION

In summary, this TBL module effectively integrates the foundational and clinical sciences to teach higher-order concepts in immunology and renal disease pathogenesis to medical students.

Microbiome in Rheumatoid Arthritis and Celiac Disease: A Friend or Foe

Rheumatoid arthritis (RA) and celiac disease (CD) are both autoimmune diseases with increasing global prevalence. These two diseases have been connected based on similar HLA mutations, serological markers, rheumatological, and gastrointestinal manifestations. In this review, we discuss the role of the oral and gut microbiome in the development and progression of RA and CD. Here, we highlight similar microbial dysbiosis and how these alterations in composition can lead to worsening disease severity in both CD and RA. Additionally, we analyze the role of probiotics in regulating the microbiome and improving symptoms associated with RA and CD.

Psoriasis: To Vaccinate or Not to Vaccinate?

Psoriasis is a chronic, inflammatory, autoimmune disease characterized by red, dry, itchy, and scaly patches of abnormal skin growth on the elbows, knees, and/or scalp, which can negatively impact a patient's quality of life and activities of daily living. Both genetic predispositions and environmental factors, which can vary in susceptibility and effect, including infection, stress, medications, and cold temperatures, can lead to the onset of psoriasis and progression of the condition. This review aims to highlight recent advances in understanding the pathophysiology of psoriasis and provide insight into the importance of vaccinations and their role in reducing the risk of infection in psoriasis patients. Vaccination has been shown to reduce the risk of infection in psoriasis patients and those with other autoimmune diseases. Still, vaccination remains limited among autoimmune disease patients. Awareness of the benefits of vaccination needs to be raised among healthcare professionals due to the overarching impact on these patients' lives. The focus of this literature review is to examine the existing data to determine whether vaccination is beneficial for psoriasis patients. Herein, we primarily focus on influenza, pneumococcal, and herpes zoster vaccines and whether immunization benefits or adversely affects psoriasis patients. Overall, we found that most psoriasis and vaccine literature support immunization of this patient population, particularly with non-live attenuated vaccines; however, more studies are needed to fully develop a vaccine recommendation schedule for psoriasis patients.

A Review of the Efficacy of Influenza Vaccination in Autoimmune Disease Patients

Patients suffering from autoimmune diseases appear to be at greater risk for developing infections with the influenza virus compared to healthy controls due to their immunosuppressive treatment, suggesting the importance of vaccination. Within this literature review, we highlight the importance, efficacy, and safety of influenza vaccination in individuals with autoimmune diseases, including systemic lupus erythematosus (SLE), Sjogren syndrome (SS), rheumatoid arthritis (RA), and inflammatory bowel disease (IBD) in both vaccinated and unvaccinated individuals. Overall, vaccination is generally well tolerated by SLE patients and the literature recommends the inactivated influenza vaccine to SLE patients according to the recommendations and schedules for the general population and annually against seasonal influenza viruses. While the data are still unclear in patients with SS, there does seem to be a general consensus to vaccinate these individuals to prevent harmful risks of influenza disease. In patients with RA and IBD, vaccination efficacy with the inactivated influenza vaccine should be determined on a case-by-case basis, taking patient therapy into account. In light of the current pandemic and global coronavirus disease 2019 (COVID-19) crisis, it is crucial to emphasize the safety and immunogenicity of influenza vaccination in vulnerable individuals suffering from autoimmune diseases. Public health measures are recommended to protect these individuals with vaccinations, keeping in mind the possibility of the multiple COVID-19 vaccines that are currently available.

Repetitive Microtrauma and Negative Ulnar Variance as Possible Culprits of Avascular Necrosis of the Lunate

Kienböck’s disease is characterized by avascular necrosis of the lunate. Its pathophysiology involves a complex interplay of repetitive microtrauma, anatomical and vascular variances. Early diagnosis of this entity is challenging as disease presentation is nonspecific and can mimic common wrist pathologies such as fractured or sprained wrist. Here we report a case presentation of Kienböck’s disease Stage IIIA in a 28-year-old healthy male. Initial radiographs of the left wrist were inconclusive and two weeks later the diagnosis was confirmed with a magnetic resonance imaging. The patient was initially treated with cast immobilization for four months but remained symptomatic with no improvements in pain or function. He then elected to participate in left radial shortening osteotomy with a vascularized bone graft from the distal radius. Unfortunately, both conservative and invasive procedures did not prevent end-stage disease characterized by the complete collapse of the lunate. However, 18 months post-surgical follow-up, the patient continues to remain pain-free with no limitations to his daily living activities.

Lupus and the Liver: A Case Study

Systemic lupus erythematosus (SLE) is an autoimmune disorder with a wide range of systemic manifestations. Though skin, renal, joint, and hematologic involvement are often associated with SLE, hepatitis is not a common manifestation. While clinically significant hepatopathy in SLE is rare, asymptomatic hypertransaminasemia has been seen in up to 60 percent of SLE patients during the course of their disease and is generally attributed to viral hepatitis, hepatotoxic drugs, or alcohol use. A diagnosis of lupus hepatitis is largely considered a diagnosis of exclusion. There has been a correlation between the presence of ribosomal P autoantibodies with the incidence of lupus hepatitis. Generally, lupus hepatitis responds well to therapy with prednisone, although cases refractory to corticosteroids and conventional immunosuppressants have been described. In these cases, treatment with mycophenolate mofetil has been shown to be effective. Here, we present the case of a 15-year old female who presented with a new diagnosis of SLE with an incidental elevation of her liver function tests (LFTs) and a subsequent finding of hepatomegaly with fatty infiltration.

DPP-4 inhibitor (sitagliptin)-induced seronegative rheumatoid arthritis

Sitagliptin is a dipeptidyl peptidase-4 inhibitor commonly used in the treatment of type 2 diabetes mellitus for glycaemic control. Concerns have arisen regarding adverse events caused by this drug, particularly concerning arthralgias. Here, we report on a 56-year-old man being treated with sitagliptin who developed inflammatory arthritis after taking the drug for 6 months. The patient presented with pain, swelling and erythema in multiple joints and was eventually diagnosed with seronegative rheumatoid arthritis (RA) under the 2010 American College of Rheumatology/European League Against Rheumatism classification criteria. His symptoms continued for several months after stopping sitagliptin and eventually went into remission after a tapered course of steroids, hydroxychloroquine and methotrexate. Furthermore, the patient is HLA-DRB3 positive, a genetic marker that is still being investigated for its role in the pathogenesis of RA and that may have been a predisposing factor in the development of this patient's inflammatory arthropathy.

Reconsidering the Use of Minocycline in the Preliminary Treatment Regime of Rheumatoid Arthritis

Strong epidemiologic, clinical, and basic science studies have identified a number of factors that may lead to rheumatoid arthritis (RA) onset and progression, particularly involving the complex interplay between genomics, environmental risk factors, the breakdown of immune self-tolerance, and microbiome dysbiosis. A chronic state of inflammation established by infectious agents has long been suspected to set the stage for the development of RA. The purpose of this article is to review the contribution of the gut, lung, and oral microbiomes to the pathogenesis of RA and consider the importance of supplementing the preliminary treatment regime of RA patients with antibiotics, in particular, minocycline. Minocycline has been used in the treatment of RA due to its bacteriostatic, as well as immunomodulatory and anti-inflammatory properties. Ultimately, a short course of antibiotic treatment with minocycline may eliminate pathogenic organisms contributing to the development and progression of RA. 

Uveitis Sarcoidosis Presumably Initiated After Administration of Shingrix Vaccine

Uveitis is a form of intraocular inflammation that can occur as a result of infection, injury, vaccination, or as a systemic manifestation of autoimmune or inflammatory diseases including sarcoidosis. Sarcoidosis is an inflammatory disease that involves the formation of abnormal granulomas in multiple organ systems. The hallmark of sarcoidosis is a non-caseating granuloma seen on biopsy. Here, we present a case report of a healthy 56-year-old Caucasian female who presented with uveitis sarcoidosis that was presumably initiated after administration of the Shingrix vaccine. Shingrix is a new attenuated subunit vaccine for Varicella Zoster Virus with an AS01B adjuvant that can result in a potent immune response. The Shingrix vaccine is made using Chinese hamster ovary cells which can contaminate the final vaccination product. Together, through the process of molecular mimicry and strong induction of the immune response, administration of Shingrix may have caused or exasperated this patient’s autoimmune etiology.

KRAS-dependent sorting of miRNA to exosomes

Mutant KRAS colorectal cancer (CRC) cells release protein-laden exosomes that can alter the tumor microenvironment. To test whether exosomal RNAs also contribute to changes in gene expression in recipient cells, and whether mutant KRAS might regulate the composition of secreted microRNAs (miRNAs), we compared small RNAs of cells and matched exosomes from isogenic CRC cell lines differing only in KRAS status. We show that exosomal profiles are distinct from cellular profiles, and mutant exosomes cluster separately from wild-type KRAS exosomes. miR-10b was selectively increased in wild-type exosomes, while miR-100 was increased in mutant exosomes. Neutral sphingomyelinase inhibition caused accumulation of miR-100 only in mutant cells, suggesting KRAS-dependent miRNA export. In Transwell co-culture experiments, mutant donor cells conferred miR-100-mediated target repression in wild-type-recipient cells. These findings suggest that extracellular miRNAs can function in target cells and uncover a potential new mode of action for mutant KRAS in CRC.

KRAS-dependent sorting of miRNA to exosomes

Mutant KRAS colorectal cancer (CRC) cells release protein-laden exosomes that can alter the tumor microenvironment. To test whether exosomal RNAs also contribute to changes in gene expression in recipient cells, and whether mutant KRAS might regulate the composition of secreted microRNAs (miRNAs), we compared small RNAs of cells and matched exosomes from isogenic CRC cell lines differing only in KRAS status. We show that exosomal profiles are distinct from cellular profiles, and mutant exosomes cluster separately from wild-type KRAS exosomes. miR-10b was selectively increased in wild-type exosomes, while miR-100 was increased in mutant exosomes. Neutral sphingomyelinase inhibition caused accumulation of miR-100 only in mutant cells, suggesting KRAS-dependent miRNA export. In Transwell co-culture experiments, mutant donor cells conferred miR-100-mediated target repression in wild-type-recipient cells. These findings suggest that extracellular miRNAs can function in target cells and uncover a potential new mode of action for mutant KRAS in CRC.

ERBB4 is over-expressed in human colon cancer and enhances cellular transformation

The ERBB4 receptor tyrosine kinase promotes colonocyte survival. Herein, we tested whether ERBB4's antiapoptotic signaling promotes transformation and colorectal tumorigenesis. ERBB4 alterations in a The Cancer Genome Atlas colorectal cancer (CRC) data set stratified survival, and in a combined Moffitt Cancer Center and Vanderbilt Medical Center CRC expression data set, ERBB4 message levels were increased at all tumor stages. Similarly, western blot and immunohistochemistry on additional CRC tissue banks showed elevated ERBB4 protein in tumors. ERBB4 was highly expressed in aggressive, dedifferentiated CRC cell lines, and its knockdown in LIM2405 cells reduced anchorage-independent colony formation. In nude mouse xenograft studies, ERBB4 alone was insufficient to induce tumor establishment of non-transformed mouse colonocytes, but its over-expression in cells harboring Apc(min) and v-Ha-Ras caused a doubling of tumor size. ERBB4-expressing xenografts displayed increased activation of survival pathways, including epidermal growth factor receptor and Akt phosphorylation and COX-2 expression, and decreased apoptotic signals. Finally, ERBB4 deletion from mouse intestinal epithelium impaired stem cell replication and in vitro enteroid establishment. In summary, we report that ERBB4 is over-expressed in human CRC, and in experimental systems enhances the survival and growth of cells driven by Ras and/or WNT signaling. Chronic ERBB4 over-expression in the context of, for example, inflammation may contribute to colorectal carcinogenesis. Tumors with high receptor levels are likely to have enhanced cell survival signaling through epidermal growth factor receptor, PI3K and COX-2. These results suggest ERBB4 as a novel therapeutic target in a subset of CRC.

Optical metabolic imaging of treatment response in human head and neck squamous cell carcinoma

Optical metabolic imaging measures fluorescence intensity and lifetimes from metabolic cofactors nicotinamide adenine dinucleotide (NADH) and flavin adenine dinucleotide (FAD). These molecular level measurements provide unique biomarkers for early cellular responses to cancer treatments. Head and neck squamous cell carcinoma (HNSCC) is an attractive target for optical imaging because of easy access to the site using fiber optic probes. Two HNSCC cell lines, SCC25 and SCC61, were treated with Cetuximab (anti-EGFR antibody), BGT226 (PI3K/mTOR inhibitor), or cisplatin (chemotherapy) for 24 hours. Results show increased redox ratio, NADH α1 (contribution from free NADH), and FAD α1 (contribution from protein-bound FAD) for malignant cells compared with the nonmalignant cell line OKF6 (p<0.05). In SCC25 and SCC61 cells, the redox ratio is unaffected by cetuximab treatment and decreases with BGT226 and cisplatin treatment (p<0.05), and these results agree with standard measurements of proliferation rates after treatment. For SCC25, NADH α1 is reduced with BGT226 and cisplatin treatment. For SCC61, NADH α1 is reduced with cetuximab, BGT226, and cisplatin treatment. Trends in NADH α1 are statistically similar to changes in standard measurements of glycolytic rates after treatment. FAD α1 is reduced with cisplatin treatment (p<0.05). These shifts in optical endpoints reflect early metabolic changes induced by drug treatment. Overall, these results indicate that optical metabolic imaging has potential to detect early response to cancer treatment in HNSCC, enabling optimal treatment regimens and improved patient outcomes.

Extracellular vesicles: communication, coercion, and conditioning

Cells communicate with neighboring cells and condition their local environment by secreting soluble factors into the extracellular space. These well-studied facets of cell biology are essential for the establishment and maintenance of physiological homeostasis. However, accumulating evidence has revealed that specific ligands, enzymes, and macromolecules are distributed into the extracellular space by virtue of their association with small vesicles, which are released by a variety of cell types. Although the biological significance of such vesicles was initially debated, purification and subsequent functional studies have shown that these extracellular vesicles are bioactive organelles carrying a wide range of protein and nucleic acid cargoes. In many cases these vesicles are laden with molecules that are involved in cell signaling, although other diverse functions are being revealed at a rapid pace. In this Perspective, we discuss recent developments in the understanding of the major pathways of extracellular vesicle biogenesis and how these vesicles contribute to the maintenance of physiological homeostasis.

Proteomic analysis of exosomes from mutant KRAS colon cancer cells identifies intercellular transfer of mutant KRAS

Activating mutations in KRAS occur in 30% to 40% of colorectal cancers. How mutant KRAS alters cancer cell behavior has been studied intensively, but non-cell autonomous effects of mutant KRAS are less understood. We recently reported that exosomes isolated from mutant KRAS-expressing colon cancer cells enhanced the invasiveness of recipient cells relative to exosomes purified from wild-type KRAS-expressing cells, leading us to hypothesize mutant KRAS might affect neighboring and distant cells by regulating exosome composition and behavior. Herein, we show the results of a comprehensive proteomic analysis of exosomes from parental DLD-1 cells that contain both wild-type and G13D mutant KRAS alleles and isogenically matched derivative cell lines, DKO-1 (mutant KRAS allele only) and DKs-8 (wild-type KRAS allele only). Mutant KRAS status dramatically affects the composition of the exosome proteome. Exosomes from mutant KRAS cells contain many tumor-promoting proteins, including KRAS, EGFR, SRC family kinases, and integrins. DKs-8 cells internalize DKO-1 exosomes, and, notably, DKO-1 exosomes transfer mutant KRAS to DKs-8 cells, leading to enhanced three-dimensional growth of these wild-type KRAS-expressing non-transformed cells. These results have important implications for non-cell autonomous effects of mutant KRAS, such as field effect and tumor progression.

Abstract 273: Exosome targeted receptor activation (ExTRAcrine) signaling: A new mode of EGF receptor ligand signaling

Epidermal growth factor receptor (EGFR) ligands have been shown to act in an autocrine, paracrine and juxtacrine manner. We report a new mode of signaling - via exosomes. Exosomes are 30-100 nm nano-vesicles that are produced by intralumenal budding into multivesicular bodies (MVB); they are released from many cell types after fusion of the MVB with the plasma membrane. Our studies showed that human breast and colorectal cancer cell lines differ in the composition of EGFR ligands in exosomes isolated from conditioned medium by established methods. By fluorescent-activated vesicle sorting (FAVS; Mol Cell Proteomics 7: 1651-1667, 2008), we show that a single HCA-7-derived exosome contains TGF-α, amphiregulin (AR) and HB-EGF. Ligands localized in exosomes are signaling competent with the ectodomains presented on the outside and cytoplasmic tails on the inside, and exist as stable transmembrane proteins. To explore the biological function of individual ligands, we isolated exosomes from MDCK cells individually stably expressing TGF-α, AR or HB-EGF. We assessed the invasive capacity of these exosomes by incubating them with a breast cancer-derived cell line (LM2-4175) in a Boyden chamber assay and measured the number of invading cells 72 hours later. Exosomes purifed from MDCK cells singly expressing AR induced invasion of LM2-4175 recipient cells 4-fold more than TGF-α or HB-EGF exosomes and 15-30-fold more than recombinant ligands TGF-α, HB-EGF or AR). The number of invading cells exposed to AR exosomes was significantly inhibited by an AR neutralizing antibody, suggesting that the invasive capacity of recipient cells is dependent upon exosomal AR engagement with recipient cell EGFR. Fixed and live cell imaging by confocal microscopy showed that AR exosomes are internalized by recipient cells. Further analysis showed that exosomes isolated from mutant KRAS DLD-1 colon cancer cells increased invasion of LM2-4175 cells 5-fold more than exosomes isolated from cells in which mutant KRAS was eliminated by homologous recombination (DKs-8 cells) and this correlated with increased levels of exosomal AR present in DLD-1 cells compared to DKs-8 cells. We provide the first evidence that EGFR ligands are present in exosomes and demonstrate that AR exosomes confer a greater invasive effect on recipient cells than TGF-α and HB-EGF exosomes or recombinant EGFR ligands. We propose ExTRAcrine signaling as a novel mode of EGFR ligand signaling with important diagnostic and therapeutic implications.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 273.