Ovarian malignancy in an individual with 46,XY ovotesticular disorder of sexual development - A case report

Disorders of sexual development (DSD) are diseases resulting from aberrations in sex chromosomes, gonadal, and internal/external genitalia development resulting in various phenotypes. Ovotesticular DSD represents a rarer entity in this classification of disorders characterized by simultaneous presence of testicular and ovarian tissue. Gonadal tumors in those with DSDs is a known risk, although ovarian masses discovered in adults with ovotesticular DSD is a rare entity and there is little literature pertaining to this population. We present a case of an incidental adnexal mass discovered in an elderly patient ultimately elucidated as a malignant ovarian mass.

High serum levels of inflammatory markers are associated with early recurrence in patients with high-grade serous ovarian cancer after platinum therapy

OBJECTIVE

To determine if inflammatory biomarkers can predict the long-term outcome of platinum therapy in patients with high-grade serous ovarian cancer.

METHODS

Women diagnosed with high-grade serous epithelial ovarian cancer (n = 70) at a single institution were enrolled in a prospective serum collection study between 2005 and 2020. Seventeen markers of inflammation and oxidative stress were measured in serum samples on a chemistry analyzer. Association was tested for serum levels with progression-free survival (PFS), time to recurrence (TTR), overall survival (OS), and time to death (TTD) using Cox proportional hazards and Kaplan-Meier curves. Patient survival was censored at 10 years.

RESULTS

Higher serum levels of LDH were associated with worse PFS (HR 2.57, p = 0.028). High serum levels of BAP (HR 0.38, p = 0.025), GSP (HR 0.40, p = 0.040), HDL-c (HR 0.27, p = 0.002), and MG (HR 0.36, p = 0.017) were associated with improved PFS. Higher expression of LDH was associated with worse OS (HR 2.16, p = 0.023). Higher levels of CK.nac (HR 0.39, p = 0.033) and HDL-c (HR 0.35, p = 0.029) were associated with improved OS. Similar outcomes were found with TTR and TTD analyses.

CONCLUSION

General inflammatory biomarkers may serve as a guide for prognosis and treatment benefit. Future studies needed to further define their role in predicting prognosis or how these markers may affect response to therapy.

Ovarian recurrence risk assessment using machine learning, clinical information, and serum protein levels to predict survival in high grade ovarian cancer

In ovarian cancer, there is no current method to accurately predict recurrence after a complete response to chemotherapy. Here, we develop a machine learning risk score using serum proteomics for the prediction of early recurrence of ovarian cancer after initial treatment. The developed risk score was validated in an independent cohort with serum collected prospectively during the remission period. In the discovery cohort, patients scored as low-risk had a median time to recurrence (TTR) that was not reached at 10 years compared to 10.5 months (HR 4.66, p < 0.001) in high-risk patients. In the validation cohort, low-risk patients had a median TTR which was not reached compared to 4.7 months in high-risk patients (HR 4.67, p = 0.009). In advanced-stage patients with a CA125 < 10, low-risk patients had a median TTR of 68 months compared to 6 months in high-risk patients (HR 2.91, p = 0.02). The developed risk score was capable of distinguishing the duration of remission in ovarian cancer patients. This score may help guide maintenance therapy and develop innovative treatments in patients at risk at high-risk of recurrence.

Synthesis, Characterization, and Reduction of Thorium Pyridinediimine Complexes

A family of thorium complexes featuring the redox-noninnocent pyridinediimine ligand MesPDIMe was synthesized, including (MesPDIMe)ThCl4 (1-Th), (MesPDIMe)ThCl3(THF) (2-Th), (MesPDIMe)ThCl2(THF)2 (3-Th) and [(MesPDIMe)Th(THF)]2 (5-Th) Full characterization of these species shows that these complexes feature MesPDIMe in four different oxidation states. The electronic structures of these complexes have been explored using 1H NMR and electronic absorption spectroscopies, X-ray crystallography, and SQUID magnetometry where appropriate.

Delivering person-centred dementia care: Perceptions of radiography practitioners within diagnostic imaging and radiotherapy departments

INTRODUCTION

Despite abundant literature on the diagnosis of dementia, limited research has explored the lived experiences of radiography practitioners when providing care to people living with dementia in the department.

OBJECTIVES

This qualitative study explored the perceptions and compatibility of current professional guidance by both diagnostic imaging and radiotherapeutic radiography practitioners as well as the key stakeholders involved with developing the Society and College of Radiographers clinical practice guidelines for caring for people with dementia.

METHODS

This was a two-phase multi-method study. Fifteen diagnostic imaging and two therapeutic radiography practitioners from across the UK participated with online focus group discussions. Four key stakeholders involved with the development of the Society and College of Radiographers guidelines took part with individual semi-structured interviews. Data analysis included narrative and thematic analysis.

RESULTS

Participants from both phases identified enablers and barriers to providing person-centred dementia care. Three superordinate themes were identified linked to (1) Working with care partners, (2) Departmental environmental design, and (3) Communication and interprofessional infrastructure.

DISCUSSION

Many radiography practitioners still feel unprepared when caring for people living with dementia despite the clinical practice guidelines. Care partners were identified as having the potential to help alleviate some of the challenges radiographers faced. Participants were also aware of the impact of the departmental environment and recognised that poor way finding designs could lead to frustration. Radiography practitioners were not always aware that a patient was living with dementia prior to their attendance in the department making it difficult for practitioners to make appropriate accommodations such as additional time at appointments or the departmental environment. Our findings suggest there is a need for profession specific education and training for radiography practitioners to support the provision of person-centred dementia care. There is also a need to support the design of dementia friendly diagnostic imaging and radiotherapy departments.

Optimising care and the patient experience for people living with dementia: The perceptions of radiography practitioners

INTRODUCTION

Despite abundant literature on the diagnosis of dementia, limited research has explored the lived experiences by radiography practitioners when delivering care to people living with dementia (PLWD). This study explored the perceptions and compatibility of current professional guidance by both radiography practitioners and key stakeholders involved in developing the Society and College of Radiographers clinical practice guideline document for caring for people with dementia.

METHODS

This was a two-stage qualitative multi-method study. Fifteen diagnostic and two therapeutic radiography practitioners from across the UK participated with three asynchronous online discussion forums. One core member and three members from the key stakeholder group participated with individual semi-structured interviews. Data analysis included narrative and thematic analysis.

RESULTS

Participants from both stages identified enablers and barriers to providing person-centred care (PCC) to PLWD. Three superordinate themes were identified linked to (1) Challenges in delivering person-centred care to people living with dementia, (2) The need for role specific education and training, and (3) Partnership working with carers. Challenges in delivering care included time and resource pressures. The lack of dementia specific education compounded these difficulties. Care partners were seen as an asset to providing care.

CONCLUSION

Providing PCC to meet the individual needs of PLWD can be challenging in practice. This is often due to time and resource implications. There were also issues with the identification of PLWD prior to their attendance in the department. Carers could help to alleviate some challenges. There is a need for profession specific education and dementia awareness training to support the provision of PCC to PLWD.

IMPLICATIONS FOR PRACTICE

Dementia training needs to be specifically tailored for radiography practitioners to bridge the gap between guidelines and clinical practice rather than being generalised from other disciplines.

Programs and interventions promoting health equity in LGBTQ2+ populations in Canada through action on social determinants of health

Sexual and gender minorities (SGM) experience a number of health inequities. That social determinants of health drive these inequities is well-documented, but there is little evidence on the number and types of interventions across Canada that address these determinants for these populations. We conducted an environmental scan of programs in Canada that target SGM, and classified the programs based on their level of intervention (individual/interpersonal, institutional and structural). We found that few programs target women, mid-life adults, Indigenous people or ethnoracial minorities, recent immigrants and refugees, and minority language speakers, and few interventions operate at a structural level.

United in earnest: first pilot sites for increased surgical capacity for rheumatic heart disease announced by cardiac surgery intersociety alliance

OBJECTIVES

Rheumatic heart disease (RHD) affects >33 000 000 individuals, mostly from low- and middle-income countries. The Cape Town Declaration on Access to Cardiac Surgery in the Developing World was published in August 2018, signalling the commitment of the global cardiac surgery and cardiology communities to improving care for patients with RHD.

METHODS

As the Cape Town Declaration formed the basis for which the Cardiac Surgery Intersociety Alliance (CSIA) was formed, the purpose of this article is to describe the history of the CSIA, its formation, ongoing activities and future directions, including the announcement of selected pilot sites.

RESULTS

The CSIA is an international alliance consisting of representatives from major cardiothoracic surgical societies and the World Heart Federation. Activities have included meetings at annual conferences, exhibit hall participation for advertisement and recruitment and publication of selection criteria for cardiac surgery centres to apply for CSIA support. Criteria focused on local operating capacity, local championing, governmental and facility support, appropriate identification of a specific gap in care and desire to engage in future research. Eleven applications were received for which 3 finalist sites were selected and site visits conducted. The 2 selected sites were Hospital Central Maputo (Mozambique) and King Faisal Hospital Kigali (Rwanda).

CONCLUSIONS

Substantial progress has been made since the passing of the Cape Town Declaration and the formation of the CSIA, but ongoing efforts with collaboration of all committed parties-cardiac surgery, cardiology, industry and government-will be necessary to improve access to life-saving cardiac surgery for patients with RHD.

Microaggression and Implicit Bias

Microaggression is an unconscious statement or action regarded as discrimination against a marginalized community. Microaggression coupled with implicit bias (unconscious prejudice in favor or against one person or group) can be psychologically damaging to the targeted community. The difficulty with microaggressions and implicit biases is that they are subjective and unconscious, and the offender may not view them as damaging. Microaggressions and implicit biases can affect both the patient and the physician. Whether it is the patient that is the victim of these phenomena or the physician, the goal of quality patient care is adversely affected. When patients are victims, bias can also lead to systematic dismissal of symptoms, inferior medical services, and less aggressive preventive care. Physicians who are victims of such phenomena may deal with the repeated trauma of receiving microaggressions and biases from patients and/or colleagues which may cause mental distress and ultimately functional impairment affecting work performance. In either case, repeated direct and indirect exposure of microaggressions and biases through encounters within and outside the workforce are cumulative leading to lasting internalized damage. Awareness that implicit biases and microaggressions exist and recognition that these phenomena are problematic are the first steps toward fostering a more equitable and inclusive culture. As a society and especially as health care workers, we must become increasingly culturally aware and sensitive of all communities for the ultimate good of patient care.

United in earnest: First pilot sites for increased surgical capacity for rheumatic heart disease announced by Cardiac Surgery Intersociety Alliance

BACKGROUND

Rheumatic heart disease affects more than 33,000,000 individuals, mostly from low- and middle-income countries. The Cape Town Declaration on Access to Cardiac Surgery in the Developing World was published in August 2018, signaling the commitment of the global cardiac surgery and cardiology communities to improving care for rheumatic heart disease patients.

METHODS

As the Cape Town Declaration formed the basis for which the Cardiac Surgery Intersociety Alliance was formed, the purpose of this article is to describe the history of the Cardiac Surgery Intersociety Alliance, its formation, ongoing activities, and future directions, including the announcement of selected pilot sites.

RESULTS

The Cardiac Surgery Intersociety Alliance is an international alliance consisting of representatives from major cardiothoracic surgical societies and the World Heart Federation. Activities have included meetings at annual conferences, exhibit hall participation for advertisement and recruitment, and publication of selection criteria for cardiac surgery centers to apply for Cardiac Surgery Intersociety Alliance support. Criteria focused on local operating capacity, local championing, governmental and facility support, appropriate identification of a specific gap in care and desire to engage in future research. Eleven applications were received for which three finalist sites were selected and site visits conducted. The two selected sites were Hospital Central Maputo (Mozambique) and King Faisal Hospital Kigali (Rwanda).

CONCLUSIONS

Substantial progress has been made since the passing of the Cape Town Declaration and the formation of the Cardiac Surgery Intersociety Alliance, but ongoing efforts with collaboration of all committed parties-cardiac surgery, cardiology, industry, and government-will be necessary to improve access to life-saving cardiac surgery for rheumatic heart disease patients.

United in earnest: First pilot sites for increased surgical capacity for rheumatic heart disease announced by Cardiac Surgery Intersociety Alliance

BACKGROUND

Rheumatic heart disease (RHD) affects more than 33,000,000 individuals, mostly from low- and middle-income countries. The Cape Town Declaration On Access to Cardiac Surgery in the Developing World was published in August 2018, signaling the commitment of the global cardiac surgery and cardiology communities to improving care for RHD patients.

METHODS

As the Cape Town Declaration formed the basis for which the Cardiac Surgery Intersociety Alliance (CSIA) was formed, the purpose of this article is to describe the history of the CSIA, its formation, ongoing activities, and future directions, including the announcement of selected pilot sites.

RESULTS

The CSIA is an international alliance consisting of representatives from major cardiothoracic surgical societies and the World Heart Federation. Activities have included meetings at annual conferences, exhibit hall participation for advertisement and recruitment, and publication of selection criteria for cardiac surgery centers to apply for CSIA support. Criteria focused on local operating capacity, local championing, governmental and facility support, appropriate identification of a specific gap in care, and desire to engage in future research. Eleven applications were received for which three finalist sites were selected and site visits conducted. The two selected sites were Hospital Central Maputo (Mozambique) and King Faisal Hospital Kigali (Rwanda).

CONCLUSIONS

Substantial progress has been made since the passing of the Cape Town Declaration and the formation of the CSIA, but ongoing efforts with collaboration of all committed parties-cardiac surgery, cardiology, industry, and government-will be necessary to improve access to life-saving cardiac surgery for RHD patients.

United in Earnest: First Pilot Sites for Increased Surgical Capacity for Rheumatic Heart Disease Announced by Cardiac Surgery Intersociety Alliance

BACKGROUND

Rheumatic heart disease (RHD) affects more than 33,000,000 individuals, mostly from low- and middle-income countries. The Cape Town Declaration On Access to Cardiac Surgery in the Developing World was published in August 2018, signaling the commitment of the global cardiac surgery and cardiology communities to improving care for RHD patients.

METHODS

As the Cape Town Declaration formed the basis for which the Cardiac Surgery Intersociety Alliance (CSIA) was formed, the purpose of this article is to describe the history of the CSIA, its formation, ongoing activities, and future directions, including the announcement of selected pilot sites.

RESULTS

The CSIA is an international alliance consisting of representatives from major cardiothoracic surgical societies and the World Heart Federation. Activities have included meetings at annual conferences, exhibit hall participation for advertisement and recruitment, and publication of selection criteria for cardiac surgery centers to apply for CSIA support. Criteria focused on local operating capacity, local championing, governmental and facility support, appropriate identification of a specific gap in care, and desire to engage in future research. Eleven applications were received for which three finalist sites were selected and site visits conducted. The two selected sites were Hospital Central Maputo (Mozambique) and King Faisal Hospital Kigali (Rwanda).

CONCLUSIONS

Substantial progress has been made since the passing of the Cape Town Declaration and the formation of the CSIA, but ongoing efforts with collaboration of all committed parties-cardiac surgery, cardiology, industry, and government-will be necessary to improve access to life-saving cardiac surgery for RHD patients.

Cardiovascular Functional Reserve Before and After Kidney Transplant

Importance

Restitution of kidney function by transplant confers a survival benefit in patients with end-stage renal disease. Investigations of mechanisms involved in improved cardiovascular survival have relied heavily on static measures from echocardiography or cardiac magnetic resonance imaging and have provided conflicting results to date.

Objectives

To evaluate cardiovascular functional reserve in patients with end-stage renal disease before and after kidney transplant and to assess functional and morphologic alterations of structural-functional dynamics in this population.

Design, Setting, and Participants

This prospective, nonrandomized, single-center, 3-arm, controlled cohort study, the Cardiopulmonary Exercise Testing in Renal Failure and After Kidney Transplantation (CAPER) study, included patients with stage 5 chronic kidney disease (CKD) who underwent kidney transplant (KTR group), patients with stage 5 CKD who were wait-listed and had not undergone transplant (NTWC group), and patients with hypertension only (HTC group) seen at a single center from April 1, 2010, to January 1, 2013. Patients were followed up longitudinally for up to 1 year after kidney transplant. Clinical data collection was completed February 2014. Data analysis was performed from June 1, 2014, to March 5, 2015. Further analysis on baseline and prospective data was performed from June 1, 2017, to July 31, 2019.

Main Outcomes and Measures

Cardiovascular functional reserve was objectively quantified using state-of-the-art cardiopulmonary exercise testing in parallel with transthoracic echocardiography.

Results

Of the 253 study participants (mean [SD] age, 48.5 [12.7] years; 141 [55.7%] male), 81 were in the KTR group, 85 in the NTWC group, and 87 in the HTC group. At baseline, mean (SD) maximum oxygen consumption (V̇O2max) was significantly lower in the CKD groups (KTR, 20.7 [5.8] mL · min-1 · kg-1; NTWC, 18.9 [4.7] mL · min-1 · kg-1) compared with the HTC group (24.9 [7.1] mL · min-1 · kg-1) (P < .001). Mean (SD) cardiac left ventricular mass index was higher in patients with CKD (KTR group, 104.9 [36.1] g/m2; NTWC group, 113.8 [37.7] g/m2) compared with the HTC group (87.8 [16.9] g/m2), (P < .001). Mean (SD) left ventricular ejection fraction was significantly lower in the patients with CKD (KTR group, 60.1% [8.6%]; NTWC group, 61.4% [8.9%]) compared with the HTC group (66.1% [5.9%]) (P < .001). Kidney transplant was associated with a significant improvement in V̇O2max in the KTR group at 12 months (22.5 [6.3] mL · min-1 · kg-1; P < .001), but the value did not reach the V̇O2max in the HTC group (26.0 [7.1] mL · min-1 · kg-1) at 12 months. V̇O2max decreased in the NTWC group at 12 months compared with baseline (17.7 [4.1] mL · min-1 · kg-1, P < .001). Compared with the KTR group (63.2% [6.8%], P = .02) or the NTWC group (59.3% [7.6%], P = .003) at baseline, transplant was significantly associated with improved left ventricular ejection fraction at 12 months but not with left ventricular mass index.

Conclusions and Relevance

The findings suggest that kidney transplant is associated with improved cardiovascular functional reserve after 1 year. In addition, cardiopulmonary exercise testing was sensitive enough to detect a decline in cardiovascular functional reserve in wait-listed patients with CKD. Improved V̇O2max may in part be independent from structural alterations of the heart and depend more on ultrastructural changes after reversal of uremia.

632. A Randomized, Placebo-Controlled, Double-Blind, Clinical Trial Evaluating Two Dose Regimens of Rifaximin (550mg daily or twice-daily) for Chemoprophylaxis Against Travelers’ Diarrhea Among Deployed U.S. and U.K. Military Personnel (PREVENT TD)

Background

Travelers’ diarrhea (TD) is a leading threat to military readiness. Most trials of rifaximin chemoprophylaxis involve civilians or short-duration travel, whereas military travelers are exposed for longer periods at austere locations and are often physically taxed. We sought to assess efficacy of two regimens among military personnel deployed overseas.

Methods

This was a multi-site, double-blind, placebo-controlled trial of deployed military, randomized to placebo, rifaximin 550 mg daily, or rifaximin 550 mg twice-daily, for up to 42 days (1:1:1; 6 randomizations/block). Diaries were reviewed with subjects on return. Primary endpoint was time to first unformed stool (TFUS) in a TD episode. Other endpoints were assessed by intention to treat (ITT) and subgroups included incidence of any loose stool, meeting criteria for TD, safety, efficacy, adherence and impact to activity endpoints.

Results

343 subjects were included in the ITT population. All UK travelers deployed to a single-site in Kenya; US travelers mostly deployed to various Asia-Pacific locations. Of 73 (21.2%) subjects reporting diarrhea, 42 (57.5%) met TD criteria. Among rifaximin-treated subjects, 15.9% (n=17) reported diarrhea in the twice-daily arm, 20.7% (n=25) in the daily arm, vs. 27.0% (n=31) of placebo recipients; p=.04 and 0.26 respectively. TD was reported by 10.3% (n=11) and 10.7% (n=13) in the daily and twice-daily arms, vs. 15.7% (n=18) among placebo recipients; p=0.24 vs. 0.26 respectively. Among UK personnel, a twice-daily regimen vs. placebo resulted in significantly fewer TD episodes (1.6% vs. 11.9%; p=0.03). Adverse events were similar between groups.

Table 1: Demographics, endpoints, and adverse events (Comparisons are across placebo vs. each dosing regimen. Intent-to-treat [ITT] population defined as subjects enrolled into the study, randomized, travelled and had follow-up. p-values calculated from chi-square or Fisher’s exact test [categorical variables] and Wilcoxon-Mann-Whitney test [continuous variables]. Analyses performed on SAS v9.4. BID: twice-daily)

Conclusion

This is the first trial comparing two high-dose regimens of rifaximin prophylaxis in deployed personnel. Unlike prior reports, neither regimen was associated with an overall significant decrease in TD, potentially due to low overall TD incidence. However, the twice-daily regimen was associated with a numerically lower incidence of diarrheal stool, and in the UK subject group, there was a significant decrease of both TD and diarrheal stool. The impact of variability in regional TD risk, pathogen distribution and adherence in austere deployment environments on efficacy will be reviewed.

Disclosures

All Authors: No reported disclosures

The impact of teaching experimental research on-line: Research-informed teaching and COVID-19

Introduction

As part of the BSc (Hons) Diagnostic Radiography programme students learn and undertake research relevant to their development as first post radiographers (dose optimisation and image quality) within the Research-Informed Teaching experience (RiTe). Due to the COVID-19 pandemic, the delivery of RiTe to our year 2 students was moved to an online format using Microsoft Teams and Blackboard Collaborate and focused on a key area of current practice - COVID-19 and chest X-ray imaging. Within RiTe students are placed into collaborative enquiry-based learning (CEBL) groups to share tasks, but to also support and learn from one another.

Methods

An online survey was used to explore the year 2 student cohort task value and self-efficacy of this online version of RiTe.

Results

A 73% (32/44) response rate was achieved. Students found the online version of RiTe to be a positive learning and development experience. There was strong agreement that they not only found it relevant to their area of practice (task-value), but also strongly agreed that they understood and could master the skills taught (self-efficacy).

Conclusion

This online version of RiTe was effectively structured to help scaffold student learning and development of research data analysis skills despite the lack of face-to-face teaching. The students also valued the topic area (COVID-19 and chest X-ray imaging). A blended learning approach with RiTe will be used next year with a combination of collaborative online teaching and physical data collection and analysis in the university-based X-ray imaging laboratory. Further evaluation and data collection will also be undertaken.

Implications for practice

University-based empirical work in groups to learn about research can be replaced by an online mechanism whilst still maintaining task-value and acceptable self-efficacy.

Molecular variations in uterine carcinosarcomas identify therapeutic opportunities

OBJECTIVE

To perform comprehensive genomic profiling on a large cohort of patients with uterine carcinosarcomas to identify potential therapeutic targets.

METHODS

Molecular profiling was conducted on 168 retrospectively de-identified patients with uterine carcinosarcomas using the Caris Life Sciences platform. Specimens were evaluated for aberrations in protein expression by immunohistochemistry, DNA sequence mutation using a 592-gene next generation sequencing panel, copy number amplification using next generation sequencing or in situ hybridization, and fusion events using NextGen RNA sequencing. Tumor mutational load and microsatellite instability were also evaluated.

RESULTS

We identified 168 patients with uterine carcinosarcoma; median age of the cohort was 67 years. The most common mutations were observed in the following genes: TP53 (86%), PIK3CA (34%), FBXW7 (23%), PTEN (18%), KRAS (16%), PPP2R1A (10%). Tumor mutational load was low to moderate in most cases (50% and 45%, respectively). HER2/neu (ERBB2) was amplified in 9% of tumors. Immunohistochemistry protein expression was elevated in TOP2A (95%), TS (80%), PTEN (76%), and TUBB3 (66%). Mismatch repair deficiency was rare (4%).

CONCLUSIONS

Multiple somatic mutations and copy number alterations in genes that are therapeutic targets were identified in half of cases. Uterine carcinosarcomas represent an aggressive histology with limited treatment options and poor outcomes, and clinical trials are needed to validate new therapeutic targets.

Disruption of the Orion molecular core 1 by wind from the massive star θ1 Orionis C

Massive stars inject mechanical and radiative energy into the surrounding environment, which stirs it up, heats the gas, produces cloud and intercloud phases in the interstellar medium, and disrupts molecular clouds (the birth sites of new stars^1,2). Stellar winds, supernova explosions and ionization by ultraviolet photons control the lifetimes of molecular clouds^3-7. Theoretical studies predict that momentum injection by radiation should dominate that by stellar winds⁸, but this has been difficult to assess observationally. Velocity-resolved large-scale images in the fine-structure line of ionized carbon ([C II]) provide an observational diagnostic for the radiative energy input and the dynamics of the interstellar medium around massive stars. Here we report observations of a one-square-degree region (about 7 parsecs in diameter) of Orion molecular core 1-the region nearest to Earth that exhibits massive-star formation-at a resolution of 16 arcseconds (0.03 parsecs) in the [C II] line at 1.9 terahertz (158 micrometres). The results reveal that the stellar wind originating from the massive star θ¹ Orionis C has swept up the surrounding material to create a 'bubble' roughly four parsecs in diameter with a 2,600-solar-mass shell, which is expanding at 13 kilometres per second. This finding demonstrates that the mechanical energy from the stellar wind is converted very efficiently into kinetic energy of the shell and causes more disruption of the Orion molecular core 1 than do photo-ionization and evaporation or future supernova explosions.

Long- and short-term outcomes in renal allografts with deceased donors: A large recipient and donor genome-wide association study

Improvements in immunosuppression have modified short-term survival of deceased-donor allografts, but not their rate of long-term failure. Mismatches between donor and recipient HLA play an important role in the acute and chronic allogeneic immune response against the graft. Perfect matching at clinically relevant HLA loci does not obviate the need for immunosuppression, suggesting that additional genetic variation plays a critical role in both short- and long-term graft outcomes. By combining patient data and samples from supranational cohorts across the United Kingdom and European Union, we performed the first large-scale genome-wide association study analyzing both donor and recipient DNA in 2094 complete renal transplant-pairs with replication in 5866 complete pairs. We studied deceased-donor grafts allocated on the basis of preferential HLA matching, which provided some control for HLA genetic effects. No strong donor or recipient genetic effects contributing to long- or short-term allograft survival were found outside the HLA region. We discuss the implications for future research and clinical application.

Quality of life measures predict cardiovascular health and physical performance in chronic renal failure patients

BACKGROUND

Patients with advanced chronic kidney disease (CKD) experience complex functional and structural changes of the cardiopulmonary and musculoskeletal system. This results in reduced exercise tolerance, quality of life and ultimately premature death. We investigated the relationship between subjective measures of health related quality of life and objective, standardised functional measures for cardiovascular and pulmonary health.

METHODS

Between April 2010 and January 2013, 143 CKD stage-5 or CKD5d patients (age 46.0±1.1y, 62.2% male), were recruited prospectively. A control group of 83 healthy individuals treated for essential hypertension (HTN; age 53.2±0.9y, 48.22% male) were recruited at random. All patients completed the SF-36 health survey questionnaire, echocardiography, vascular tonometry and cardiopulmonary exercise testing.

RESULTS

Patients with CKD had significantly lower SF-36 scores than the HTN group; for physical component score (PCS; 45.0 vs 53.9, p<0.001) and mental component score (MCS; 46.9 vs. 54.9, p<0.001). CKD subjects had significantly poorer exercise tolerance and cardiorespiratory performance compared with HTN (maximal oxygen uptake; VO2peak 19.9 vs 25.0ml/kg/min, p<0.001). VO2peak was a significant independent predictor of PCS in both groups (CKD: b = 0.35, p = 0.02 vs HTN: b = 0.27, p = 0.001). No associations were noted between PCS scores and echocardiographic characteristics, vascular elasticity and cardiac biomarkers in either group. No associations were noted between MCS and any variable. The interaction effect of study group with VO2peak on PCS was not significant (ΔB = 0.08; 95%CI -0.28-0.45, p = 0.7). However, overall for a given VO2peak, the measured PCS was much lower for patients with CKD than for HTN cohort, a likely consequence of systemic uremia effects.

CONCLUSION

In CKD and HTN, objective physical performance has a significant effect on quality of life; particularly self-reported physical health and functioning. Therefore, these quality of life measures are indeed a good reflection of physical health correlating highly with objective physical performance measures.

A phase 2, randomized, double-blind, placebo- controlled study of chemo-immunotherapy combination using motolimod with pegylated liposomal doxorubicin in recurrent or persistent ovarian cancer: a Gynecologic Oncology Group partners study

BACKGROUND

A phase 2, randomized, placebo-controlled trial was conducted in women with recurrent epithelial ovarian carcinoma to evaluate the efficacy and safety of motolimod-a Toll-like receptor 8 (TLR8) agonist that stimulates robust innate immune responses-combined with pegylated liposomal doxorubicin (PLD), a chemotherapeutic that induces immunogenic cell death.

PATIENTS AND METHODS

Women with ovarian, fallopian tube, or primary peritoneal carcinoma were randomized 1 : 1 to receive PLD in combination with blinded motolimod or placebo. Randomization was stratified by platinum-free interval (≤6 versus >6-12 months) and Gynecologic Oncology Group (GOG) performance status (0 versus 1). Treatment cycles were repeated every 28 days until disease progression.

RESULTS

The addition of motolimod to PLD did not significantly improve overall survival (OS; log rank one-sided P = 0.923, HR = 1.22) or progression-free survival (PFS; log rank one-sided P = 0.943, HR = 1.21). The combination was well tolerated, with no synergistic or unexpected serious toxicity. Most patients experienced adverse events of fatigue, anemia, nausea, decreased white blood cells, and constipation. In pre-specified subgroup analyses, motolimod-treated patients who experienced injection site reactions (ISR) had a lower risk of death compared with those who did not experience ISR. Additionally, pre-treatment in vitro responses of immune biomarkers to TLR8 stimulation predicted OS outcomes in patients receiving motolimod on study. Immune score (tumor infiltrating lymphocytes; TIL), TLR8 single-nucleotide polymorphisms, mutational status in BRCA and other DNA repair genes, and autoantibody biomarkers did not correlate with OS or PFS.

CONCLUSIONS

The addition of motolimod to PLD did not improve clinical outcomes compared with placebo. However, subset analyses identified statistically significant differences in the OS of motolimod-treated patients on the basis of ISR and in vitro immune responses. Collectively, these data may provide important clues for identifying patients for treatment with immunomodulatory agents in novel combinations and/or delivery approaches.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT 01666444.

Acute renal allograft rejection after immune checkpoint inhibitor therapy for metastatic melanoma

Immune checkpoint inhibitors such as ipilimumab and nivolumab improve survival in patients with advanced melanoma and are increasingly available to clinicians for use in the clinic. Their safety in organ transplant recipients is not well defined but published case reports describing treatment with ipilimumab have not been complicated by graft rejection. No cases of anti-programmed cell death protein 1 administration are reported in this group. We describe a case of acute graft rejection in a kidney transplant recipient after treatment with nivolumab, after progression on ipilimumab. Potential factors increasing the risk of graft rejection in this case are discussed, in particular the contribution of nivolumab.

Kidney Transplantation Significantly Improves Patient and Graft Survival Irrespective of BMI: A Cohort Study

Obesity and end-stage renal disease (ESRD) are on the increase worldwide. Kidney transplantation is the treatment of choice for ESRD. However, obesity is considered a contraindication for transplantation. We investigated the effect of BMI on mortality in transplanted and patients remaining on the waiting list in the United Kingdom. We analyzed the UK Renal Registry (RR) and the National Health Service Blood and Transplant (NHSBT) Organ Donation and Transplantation data for patients listed from January 1, 2004 to December 31, 2010, with follow-up until December 31, 2011. Seventeen thousand six hundred eighty-one patients were listed during the study period, with BMI recorded for 13 526 (77%). One- and five-year patient survival was significantly better in all BMI bands (<18.5, 18.5-<25, 25-<30, 30-<35, 35-<40, and 40+kg/m(2) ) in the transplant group when compared to those who remained on the waiting list (p < 0.0001). The analyses were repeated excluding live donor transplants and the results were essentially the same. On analyses of patient survival with BMI as a continuous variable or using 5 kg weight bands, there was no cut-off observed in the higher BMI patients where there would be no benefit to transplantation. For transplanted patients (N = 8088), there was no difference in patient or graft survival between the defined BMI bands. Thus, irrespective of BMI, patient survival is improved if transplanted.

Subclass analysis of donor HLA-specific IgG in antibody-incompatible renal transplantation reveals a significant association of IgG4 with rejection and graft failure

Donor HLA‐specific antibodies (DSAs) can cause rejection and graft loss after renal transplantation, but their levels measured by the current assays are not fully predictive of outcomes. We investigated whether IgG subclasses of DSA were associated with early rejection and graft failure. DSA levels were determined pretreatment, at the day of peak pan‐IgG level and at 30 days post‐transplantation in eighty HLA antibody‐incompatible kidney transplant recipients using a modified microbead assay. Pretreatment IgG₄ levels were predictive of acute antibody‐mediated rejection (P = 0.003) in the first 30 days post‐transplant. Pre‐treatment presence of IgG₄DSA (P = 0.008) and day 30 IgG₃DSA (P = 0.03) was associated with poor graft survival. Multivariate regression analysis showed that in addition to pan‐IgG levels, total IgG₄ levels were an independent risk factor for early rejection when measured pretreatment, and the presence of pretreatment IgG₄DSA was also an independent risk factor for graft failure. Pretreatment IgG₄DSA levels correlated independently with higher risk of early rejection episodes and medium‐term death‐censored graft survival. Thus, pretreatment IgG₄DSA may be used as a biomarker to predict and risk stratify cases with higher levels of pan‐IgG DSA in HLA antibody‐incompatible transplantation. Further investigations are needed to confirm our results.

Modulation of wound healing and scar formation by MG53 protein-mediated cell membrane repair

Cell membrane repair is an important aspect of physiology, and disruption of this process can result in pathophysiology in a number of different tissues, including wound healing, chronic ulcer and scarring. We have previously identified a novel tripartite motif family protein, MG53, as an essential component of the cell membrane repair machinery. Here we report the functional role of MG53 in the modulation of wound healing and scarring. Although MG53 is absent from keratinocytes and fibroblasts, remarkable defects in skin architecture and collagen overproduction are observed in mg53(-/-) mice, and these animals display delayed wound healing and abnormal scarring. Recombinant human MG53 (rhMG53) protein, encapsulated in a hydrogel formulation, facilitates wound healing and prevents scarring in rodent models of dermal injuries. An in vitro study shows that rhMG53 protects against acute injury to keratinocytes and facilitates the migration of fibroblasts in response to scratch wounding. During fibrotic remodeling, rhMG53 interferes with TGF-β-dependent activation of myofibroblast differentiation. The resulting down-regulation of α smooth muscle actin and extracellular matrix proteins contributes to reduced scarring. Overall, these studies establish a trifunctional role for MG53 as a facilitator of rapid injury repair, a mediator of cell migration, and a modulator of myofibroblast differentiation during wound healing. Targeting the functional interaction between MG53 and TGF-β signaling may present a potentially effective means for promoting scarless wound healing.

Exaggerated blood pressure response to dynamic exercise despite chronic refractory hypotension: results of a human case study

BACKGROUND

Chronic refractory hypotension is a rare but significant mortality risk in renal failure patients. Such aberrant physiology usually deems patient unfit for renal transplant surgery. Exercise stimulates the mechano-chemoreceptors in the skeletal muscle thereby modulating the sympathetic effects on blood pressure regulation. The haemodynamic response to dynamic exercise in such patients has not been previously investigated. We present a case with severe chronic hypotension who underwent exercise testing before and after renal transplantation, with marked differences in blood pressure response to exercise.

CASE PRESENTATION

A 40-year old haemodialysis-dependent patient with a 2 year history of refractory hypotension (≤80/50 mmHg) was referred for living donor renal transplantation at our tertiary centre. Each dialysis session was often less than 2 h and 30 min due to symptomatic hypotension. As part of the cardiovascular assessment, she underwent haemodynamic evaluation with cardiopulmonary exercise testing. Blood pressure normalized during unloaded pedalling but was exaggerated at maximal workload whereby it rose from 82/50 mmHg to a peak of 201/120 mmHg. Transthoracic echocardiography, tonometric measure of central vascular compliance and myocardial perfusion scan were normal. She subsequently underwent an antibody-incompatible renal transplantation and was vasopressor reliant for 14 days during the post-operative period. Eight weeks following transplant, resting blood pressure was normal and a physiological exercise-haemodynamic response was observed during a repeat cardiopulmonary exercise testing.

CONCLUSION

This case highlights the potential therapeutic role of unloaded leg cycling exercise during dialysis session to correct chronic hypotension, allowing patients to have greater tolerance to fluid shift. It also adds to existing evidence that sympathetic dysfunction is reversible with renal transplant. Furthermore chronic hypotension with preserved exercise-haemodynamic response and cardiovascular reserve should not preclude these patients from renal transplant surgery.