Method validation of multi-element panel in whole blood by inductively coupled plasma mass spectrometry (ICP-MS)

Background

Analytical methods to measure trace and toxic elements are essential to evaluate exposure and nutritional status. A ten-element panel was developed and validated for clinical testing in whole blood. Retrospective data analysis was conducted on patient samples performed at ARUP Laboratories.

Methods

A method was developed and validated to quantify ten elements in whole blood by ICP-MS. Fifty microliters of sample were extracted with 950 μL of diluent containing 1 % ammonium hydroxide, 0.1 % Triton X-100, 1.75 % EDTA along with spiked internal standards. Four calibrators were used for each element and prepared in goat blood to match the patient specimen matrix. Samples were analyzed with an Agilent 7700 ICP-MS with a Cetac MVX 7100 μL Workstation autosampler.

Results

The assay was linear for all elements with inter- and intra-assay imprecision less than or equal to 11% CV at the low end of the analytical measurement range (AMR) and less than or equal to 4% CV at the upper end of the AMR for all elements. Accuracy was checked with a minimum of 40 repeat patient samples, proficiency testing samples, and matrix-matched spikes. The linear slopes for the ten elements ranged from 0.94 to 1.03 with intercepts below the AMR and R² ranging from 0.97 to 1.00.

Conclusions

The multi-element panel was developed to analyze ten elements in whole blood to unify the sample preparation and increase batch run efficiency. The improved analytical method utilized matrix-matched calibrators for accurate quantification to meet regulatory requirements. The assay was validated according to guidelines for CLIA-certified clinical laboratories and was suitable for clinical testing to assess nutritional status and toxic exposure.

HPV vaccination coverage for pediatric, adolescent and young adult patients receiving care in a childhood cancer survivor program

Pediatric, adolescent and young adult patients undergoing cancer treatment and/or hematopoietic stem cell transplant are at increased risk for developing a secondary human papillomavirus (HPV)-associated malignancy. The objective of this study was to determine HPV vaccination coverage among individuals participating in a childhood cancer survivor program (CCSP). A retrospective cohort study was conducted among CCSP patients age 11–26 years attending a CCSP visit between 2014 and 2019. Survivors were age-, sex-, and race-matched 1:2 with controls without cancer. Data were abstracted from the electronic health record and state-based vaccination registry. Analysis was limited to Minnesota residents to minimize missing vaccination data. Survivorship care plans (SCPs) were reviewed for vaccine recommendations.

592 patients were included in the analyses (200 CCSP patients; 392 controls). By study design, mean age (18.4 years), race (72 % white), and sex (49 % female) were similar in the two groups. Among CCSP patients 22 % resided in a rural area compared to 3.8 % of controls. Vaccination coverage among CCSP patients was not statistically significantly different from controls [60.0 % vs 66.3 %, OR = 0.82, 95 % CI: (0.55, 1.23), p = 0.35]. Completion of 3 doses was not different between groups even though 3 doses is recommended for all CCSP patients regardless of age at initiation (28.5 % vs 30.1 %, p = 0.09). Only 8.0 % of SCPs recommended HPV vaccination.

Although patients participating in a CCSP did not have significantly different HPV vaccination coverage compared to controls, HPV vaccination initiation and 3-dose series completion are still suboptimal in a patient population at high-risk of a secondary HPV-associated cancer.

Suppression of Bile Acid Synthesis in a Preterm Infant Receiving Prolonged Parenteral Nutrition

Bile acid metabolism is altered in neonates on parenteral nutrition (PN), predisposing them to parenteral nutrition-associated liver disease. Cholesterol 7α-hydroxylase (CYP7A1), the rate-limiting enzyme in the bile acid synthesis pathway, is repressed by fibroblast growth factor 19 (FGF19) and phytosterols (PS). We describe a case of a preterm infant who developed necrotizing enterocolitis (NEC) and received exclusive PN for over 2 months. Our objective was to serially assess CYP7A1 activity and plasma FGF19 and PS concentrations in this infant case compared to five healthy preterm infants. We found that CYP7A1 activity increased during the first 2 weeks of life in control infants but was undetectable in the infant case. FGF19 concentrations were high at birth in all infants and subsequently declined and did not differ between the case and control infants. As expected, PS concentrations were elevated in the infant case and continued to increase despite lipid minimization. In conclusion, CYP7A1 activity was gradually upregulated in healthy preterm infants but remained suppressed in the infant requiring prolonged PN. Preterm infants also had elevated FGF19 concentrations at birth, which decreased with advancing postnatal age.

The West Philadelphia asthma care implementation study (NHLBI#

Asthma is the most common chronic condition among children, with low-income families living in urban areas experiencing significantly higher rates. Evidence based interventions for asthma are routinely implemented in either the home, school, or primary care setting. However, even when caregivers of poor children are engaged in asthma interventions in one setting, they often have to navigate challenges in another setting, such as an under-resourced home, non-supportive school, or disengaged health care provider. The West Philadelphia Asthma Care Implementation Plan aims to compare the effectiveness of a primary care-based intervention, school-based intervention, and combined primary care and school intervention to usual care for improving asthma control in school-age children to explore if the synergistic effect of Community Health Worker (CHW) support in the home, school, and health care environments will result in improved asthma control. Children ages 5-13 with uncontrolled asthma from four West Philadelphia recruitment sites will be eligible for enrollment. The families of school age children interested in participating will be randomized to receive a primary care CHW or usual care. Those identified as attending a participating school will have a CHW-led school intervention or usual care in school. If proven effective, this care coordination program will assist caregivers in assessing resources, improving self-management skills, and ultimately reducing asthma-related ED visits and hospitalizations as well as provide additional information for healthcare systems and policy makers to inform their decisions about how and where to focus additional resources and investments in childhood asthma care to improve health outcomes.

The influence of equitable access policies and socioeconomic factors on post-liver transplant survival

BACKGROUND

Survival following liver transplant (LT) is influenced by a variety of factors, including donor risk factors and recipient disease burden and co-morbidities. It is difficult to separate these effects from those of socioeconomic factors, such as income or insurance. The United Network for Organ Sharing (UNOS) created equitable access policies, such as Share 35, to ensure that organs are distributed to individuals with greatest medical need; however, the effect of Share 35 on disparities in post-LT survival is not clear. This study aimed to (1) characterize associations between post-transplant survival and race and ethnicity, income, insurance, and citizenship status, when adjusted for other clinical and demographic factors that may influence survival, and (2) determine if the direction of associations changed after Share 35.

METHODS

A retrospective, cohort study of adult LT recipients (n = 83,254) from the UNOS database from 2005 to 2019 was conducted. Kaplan-Meier survival graphs and stepwise multivariate cox-regression analyses were performed to characterize the effects of socioeconomic status on post-LT survival, adjusted for recipient and donor characteristics, across the time period and after Share 35.

FINDINGS

Male sex (HR: 0.93 (95% CI: 0.90-0.96)), private insurance (0.91 (0.88-0.94)), income (0.82 (0.79-0.85)), U.S. citizenship, and Asian (0.81 (0.75-0.88)) or Hispanic (0.82 (0.79-0.86)) race and ethnicity were associated with higher post-transplant survival, after adjustment for clinical and demographic factors (Table 3). These associations were found across the entire time period studied and many persisted after the implementation of Share 35 in 2013 (Table 3; male sex (0.84 (0.79-0.90)), private insurance (0.94 (0.89-1.00)), income (0.82 (0.77-0.89)), and Asian (0.87 (0.73-1.02)) or Hispanic (0.88 (0.81-0.96)) race and ethnicity).

INTERPRETATION

Recipients' socioeconomic factors at time of transplant may impact long-term post-transplant survival, and a single policy may not significantly alter these structural health inequalities.

FUNDING

None.

Outpatient and inpatient anticoagulation therapy and the risk for hospital admission and death among COVID-19 patients

BACKGROUND

Coronavirus disease 2019 (COVID-19) is associated with a hypercoagulable state. Limited data exist informing the relationship between anticoagulation therapy and risk for COVID-19 related hospitalization and mortality.

METHODS

We evaluated all patients over the age of 18 diagnosed with COVID-19 in a prospective cohort study from March 4th to August 27th, 2020 among 12 hospitals and 60 clinics of M Health Fairview system (USA). We investigated the relationship between (1) 90-day anticoagulation therapy among outpatients before COVID-19 diagnosis and the risk for hospitalization and mortality and (2) Inpatient anticoagulation therapy and mortality risk.

FINDINGS

Of 6195 patients, 598 were immediately hospitalized and 5597 were treated as outpatients. The overall case-fatality rate was 2•8% (n = 175 deaths). Among the patients who were hospitalized, the inpatient mortality was 13%. Among the 5597 COVID-19 patients initially treated as outpatients, 160 (2.9%) were on anticoagulation and 331 were eventually hospitalized (5.9%). In a multivariable analysis, outpatient anticoagulation use was associated with a 43% reduction in risk for hospital admission, HR (95% CI = 0.57, 0.38-0.86), p = 0.007, but was not associated with mortality, HR (95% CI=0.88, 0.50 - 1.52), p = 0.64. Inpatients who were not on anticoagulation (before or after hospitalization) had an increased risk for mortality, HR (95% CI = 2.26, 1.17-4.37), p = 0.015.

INTERPRETATION

Outpatients with COVID-19 who were on outpatient anticoagulation at the time of diagnosis experienced a 43% reduced risk of hospitalization. Failure to initiate anticoagulation upon hospitalization or maintaining outpatient anticoagulation in hospitalized COVID-19 patients was associated with increased mortality risk.

FUNDING

No funding was obtained for this study.

Prism Adaptation Treatment Improves Inpatient Rehabilitation Outcome in Individuals With Spatial Neglect: A Retrospective Matched Control Study

Objective

To determine whether prism adaptation treatment (PAT) integrated into the standard of care improves rehabilitation outcome in patients with spatial neglect (SN).

Design

Retrospective matched control study based on information extracted from June 2017-September 2019.

Setting

Inpatient rehabilitation.

Participants

Patients from 14 rehabilitation hospitals scoring >0 on the Catherine Bergego Scale (N=312). The median age was 69.5 years, including 152 (49%) female patients and 275 (88%) patients with stroke.

Interventions

Patients were matched 1:1 by age (±5 years), FIM score at admission (±2 points), and SN severity using the Catherine Bergego Scale (±2 points) and classified into 2 groups: treated (8-12 daily sessions of PAT) vs untreated (no PAT).

Main Outcome Measures

FIM and its minimal clinically important difference (MCID) were the primary outcome variables. Secondary outcome was home discharge.

Results

Analysis included the 312 matched patients (156 per group). FIM scores at discharge were analyzed using repeated-measures analyses of variance. The treated group showed reliably higher scores than the untreated group in Total FIM, F=5.57, P=.020, partial η²=0.035, and Cognitive FIM, F=19.20, P<.001, partial η²=0.110, but not Motor FIM, F=0.35, P=.553, partial η²=0.002. We used conditional logistic regression to examine the odds ratio of reaching MCID in each FIM score and of returning home after discharge. No reliable difference was found between groups in reaching MCID or home discharge.

Conclusions

Patients with SN receiving PAT had better functional and cognitive outcomes, suggesting that integrating PAT into the standard of care is beneficial. However, receiving PAT may not determine home discharge.

Patients' Perspective About the Cost of Diabetes Management: An Analysis of Online Health Communities

Objective

To understand the perspectives of persons' living with diabetes about the increasing cost of diabetes management through an analysis of online health communities (OHCs) and the impact of persons' participation in OHCs on their capacity and treatment burden.

Patients and Methods

A qualitative study of 556 blog posts submitted between January 1, 2007 and December 31, 2017 to 4 diabetes social networking sites was conducted between March 2018 and July 2019. All posts were coded inductively using thematic analysis procedures. Eton's Burden of Treatment Framework and Boehmer's Theory of Patient Capacity directed triangulation of themes with existing theory.

Results

Three themes were identified: (1) cost barriers to care: participants describe individual and systemic cost barriers that inhibit prescribed therapy goals; (2) impact of financial cost on health: participants describe the financial effects of care on their physical and emotional health; and (3) saving strategies to overcome cost impact: participants discuss practical strategies that help them achieve therapy goals. Finally, we also identify that the use of OHCs serves to increase persons' capacity with the potential to decrease treatment burden, ultimately improving mental and physical health.

Conclusion

High cost for diabetes care generated barriers that negatively affected physical health and emotional states. Participant-shared experiences in OHCs increased participants' capacity to manage the burden. Potential solutions include cost-based shared decision-making tools and advocacy for policy change.

Sub-chronic toxicity of ethanol leaf extract of Syzygium guineense on the biochemical parameters and histopathology of liver and kidney in the rats

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Long-term use of Syzygium guineense leaf extract reduced the food intake and weight gain in rats.

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The serum level of liver and kidney enzymes of rats was increased by the treatment of high dose of Syzygium guineense leaf.

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Use of Syzygium guineense leaf extract showed hypoglycemic effect in rats.

Background

Syzygium guineense Wall. leaf is being used as a traditional medicine against hypertension and diabetes mellitus. Unlike its efficacy, the safety profile of this plant upon long-term administration has not been investigated yet. Therefore, this study investigated the sub-chronic toxicity of S. guineense leaves in rats.

Methods

Wistar albino rats, 10/sex/group were randomly assigned into four groups. Group I-III respectively received 250, 500, and 1000 mg/kg of body weight of 70 % ethanol extract ofS. guineense leaves for 90 consecutive days. Group IV (control) received distilled water. Throughout the experiment, clinical observations were carried out, food intake and weight of the rats also were measured. Finally, different biochemical parameters, organ weight, and histopathology of liver and kidneys were evaluated.

Results

Administration of 70 % ethanol extract ofS. guineense leaves decreased food intake and body weight gain of the test animals. Rats treated with 1000 mg/kg of S. guineense extract showed significantly increased serum alanine aminotransferase, aspartate aminotransferase, and alkaline phosphatase levels. Serum urea levels also increased in female rats treated with 500 and 1000 mg/kg body weight of S. guineense. Moreover, the blood glucose level of rats treated with 1000 mg/kg body weight was significantly decreased compared to the control group. However, the histology of the liver and kidneys were not significantly altered by any of the doses administered.

Conclusion

Administration ofS. guineense in rats at a dose of 1000 mg/kg body weight affected the food consumption, weight gain, and serum levels of liver and kidney enzymes suggesting that S. guineense intake at high doses may be toxic. Therefore, liberal consumption of S. guineense leaves should be taken curiously and cautiously.

Results of a prospective cardiovascular disease prevention program

The Cardiovascular Health Program (CHP) Registry is a 12-month, prospective study of therapeutic lifestyle change (TLC). Adult participants received comprehensive assessment of health behaviors and cardiovascular disease (CVD) risk factors. Personalized TLC action plans addressed modifiable health behaviors for diet, exercise, stress management, and sleep. Participants attended a half-day interactive workshop and met face-to-face with certified health coaches four times over 6 months. Monthly telephonic coaching for 6 more months completed the intervention. Measured outcomes included adherence to behavioral prescriptions, anthropometrics, CVD-relevant laboratory tests, and for a subset of participants, carotid intima-media thickness (CIMT). Of 965 participants, 648 (67%) completed the program and were included in the analysis. Participants were of mean age 55.4 ± 12.5 years, 57% women, and racially diverse. Adherence to prescribed TLC was substantial: dietary behaviors at goal rose from 53% to 86%, exercise 44% to 66%, perceived stress 65% to 79%, and sleep quality 28% to 49%. For participants with abnormal anthropometrics at baseline, there were improvements in body mass index in 63%, waist circumference (men 71%, women 74%), systolic BP 69%, and diastolic BP 71%. For participants with abnormal laboratory values at baseline, there were improvements in total cholesterol in 74%, LDL-cholesterol 65%, triglycerides 86%, fasting glucose 72%, and insulin resistance 71%. Improvements were not driven by prescribed medications. CIMT improved or showed no change in 70% of those measured, associated with significant improvements in sleep quality and longer total sleep time. Longer trials incorporating controls and major adverse CVD events are warranted.

Study design for a randomized clinical trial of cognitive-behavioral therapy for posttraumatic headache

Posttraumatic headache (PTH) is a common debilitating condition arising from head injury and is highly prevalent among military service members and veterans with traumatic brain injury (TBI). Diagnosis and treatment for PTH is still evolving, and surprisingly little is known about the putative mechanisms that drive these headaches. This manuscript describes the design of a randomized clinical trial of two nonpharmacological (i.e., behavioral) interventions for posttraumatic headache. Design of this trial required careful consideration of PTH diagnosis and inclusion criteria, which was challenging due to the lack of standard clinical characteristics in PTH unique from other types of headaches. The treatments under study differed in clinical focus and dose (i.e., number of treatment sessions), but the trial was designed to balance the treatments as well as possible. Finally, while the primary endpoints for pain research can vary from assessments of pain intensity to objective and subjective functional measures, this trial of PTH interventions chose carefully to establish clinically relevant endpoints and to maximize the opportunity to detect significant differences between groups with two primary outcomes. All these issues are discussed in this manuscript.

Improving Contrast Enhancement in Pulmonary CTA: The value of breathing maneuvers

Purpose

To investigate contrast dynamics and artifacts associated with different breathing maneuvers during pulmonary computed tomography angiography (pCTA) in a prospective randomized clinical trial.

Method

Three different breathing maneuvers (inspiration, expiration, Mueller) were randomly assigned to 146 patients receiving pCTA for suspected pulmonary embolism (PE). Contrast enhancement of central and peripheral arteries and imaging quality of lung parenchyma were compared and analyzed. Results were compared by using the analysis of variances (ANOVA) and Kruskal-Wallis-Test.

Results

Mean enhancement in the pulmonary trunk was highest during breath-hold in inspiration (293 HU, range 195-460 HU) compared to Mueller (259 HU, range 136-429 HU, p = 0022) and expiration (267 HU, range 115-376 HU). This was similar for the right pulmonary artery (inspiration 289 HU, range 173-454 HU; Mueller 250 HU, range 119-378 HU; p = 0.007; expiration 257 HU, range 114-366 HU; p = 0.032) and left pulmonary artery (inspiration 280.3 HU, range 170-462 HU; Mueller 245 HU, range 111-371 HU; p = 0.016; expiration 252 HU, range 110-371 HU).Delineation of peripheral arteries was significantly better in inspiration vs Mueller (p = 0.006) and expiration (p = 0.049). Assessment of the lung parenchyma was significantly better in inspiration vs Mueller (p = 0.013) or expiration (p < 0.001).

Conclusions

Resting inspiratory position achieved the highest enhancement levels in central and peripheral pulmonary arteries and best image quality of the pulmonary parenchyma in comparison to other breathing maneuvers. It is necessary to train the maneuver prior to the examination in order to avoid deep inspiration with the risk of suboptimal opacification of the pulmonary arteries.

Clinical characteristics and management of iodine contrast media-related anaphylactic shock during cardiac catheterization

Objective

This study aimed to investigate the clinical characteristics and impact of intra-aortic balloon pump (IABP) implantation on the prognosis of patients with anaphylactic shock (AS) during cardiac catheterization.

Methods

We analyzed the medical records of 34 patients who had AS caused by iodine contrast media (ICM) between January 2009 and December 2019. Clinical features and treatments were analyzed, and patients were categorized into survival and dead groups. In addition, the patients were further divided into IABP and non-IABP (NIABP) groups to assess the impact on AS according to whether a IABP was used or not.

Results

Of the 417,938 patients in whom ICM was used, 34 with AS were monitored. The prevalence of AS was 0.008%. Among the 34 patients, 6 (0.001%) died from fatal anaphylactic reactions accompanying shock, 26 (76.5%) had hypotension as the first presentation of AS in the survival and dead groups (78.6% and 66.7%, respectively), and 5 (14.7%) had unconsciousness at the initial onset of AS. The subgroup analysis revealed a higher mortality in the IABP group than in the NIABP (4/9, 44.4% vs. 2/25, 8%; P = 0.031).

Conclusions

The present study suggests a low prevalence of ICM-related AS. Hypotension was more frequent in AS related to ICM, and unconsciousness at the initial onset of AS implied a poor prognosis. The use of an IABP did not improve the outcome of the patients with AS. IABP implantation should not be used as a routine treatment for patients with AS.

Association between the ABO blood group and primary knee osteoarthritis: A case-control study

Background

Recent studies have suggested association between the ABO blood group and inflammation, which was a crucial pathological process of primary knee osteoarthritis. The aim of this study was to investigate the association between the ABO blood group and primary knee osteoarthritis ​and the severity of primary knee osteoarthritis evaluated by the Kellgren/Lawrence score, as well as the histopathologic association in a subgroup of patients.

Methods

We performed a retrospective review of patients with primary knee osteoarthritis that served as the case group ​and a random sampling of healthy blood donors that served as the control group. The severity of knee osteoarthritis at the first outpatient visit was evaluated by the Kellgren/Lawrence scoring system. Further study was performed to investigate the expression of blood group antigens in synovial tissue of the knee in both cases and controls.

Results

A total of 1126 cases and 30299 controls were involved. The proportion of AB blood group was higher in the case group than in the control group (9.7% vs. 7.8%), and logistic regression revealed that the AB blood group was a risk factor of primary knee osteoarthritis (P ​= ​0.025 and 0.048 for univariate and multivariate analysis, respectively), independent of age (P ​= ​0.973) and sex (P ​= ​0.520). Patients of the blood group AB had a higher Kellgren/Lawrence score (P ​= ​0.017). The immunohistochemical study indicated association between Le^Y antigen and primary knee osteoarthritis (P ​= ​0.029).

Conclusions

This study suggested that the blood group AB was associated with primary knee osteoarthritis, as well as its radiological severity. Further study indicated that Le^Y antigen, which was related to the blood group, was associated with primary knee osteoarthritis.

Translational potential of this article

This study revealed that blood group AB and Le^Y antigen was associated with primary knee osteoarthritis, which shed new light on the nature of osteoarthritis, and the development of novel therapy for osteoarthritis.

Superior ophthalmic vein thrombosis: What radiologist and clinician must know?

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Incidental SOVT: good prognosis, self-limited and treated by anticoagulation.

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Post-traumatic and surgical SOVT: good prognosis, treated by anticoagulation.

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Septic SOVT: secondary to infections, high risk, requires specific interventions.

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Aseptic SOVT: secondary to inflammatory diseases, need to treat underlying etiology.

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CT and MRI are vital to the correct diagnosis and management of patients with SOVT.

Purpose

Superior ophthalmic vein thrombosis (SOVT) is an extremely rare condition. Few studies have been published about clinical aspects of this condition. In this study, we have studied the symptoms, underlying etiologies, treatment, pathogenesis and complication of the SOVT and we tried to classify it based on the etiology, treatment, and prognosis.

Methods

We reviewed the patients’ data from a tertiary academic referral center. Each patient with SOVT was then reviewed for symptoms associated with SOVT, underlying etiology, treatment protocol, treatment response, complications, possible pathogens, and final outcome.

Results

Twenty-four cases of SOVT were included in this study. Overall, 13 cases were diagnosed as right-sided SOVT, out of which, eight had simultaneous right-sided cavernous sinus thrombosis (CST). Eighteen cases were diagnosed to have left-sided SOVT, out of which, 11 had simultaneous left-sided CST.

Conclusions

The SOVT can be secondary to different mechanisms. The SOVT secondary to trauma, recent surgery and coagulopathy are mostly non-aggressive, and can be managed by conservative therapy and anticoagulation. The SOVT in patients with orbital cellulitis, history of active sinusitis or paranasal sinus surgery are aggressive presenting with acute orbital swelling, abscess and visual loss. This type of SOVT can be complicated by extension to the cavernous sinus and intracranial structures. These patients require urgent antibiotics therapy and sinus surgery. The most severe type of SOVT is caused by mucormycosis which may also extend intracranially resulting in stroke and is often life-threatening.

Association between aflatoxin-albumin adduct levels and tortilla consumption in Guatemalan adults

Aflatoxin B₁ (AFB₁) is a known human hepatocarcinogen and a recent study reported elevated AFB₁ levels, measured by serum albumin biomarkers, among Guatemalan adults. While AFB₁ can contaminate a variety of foodstuffs, including maize, Guatemala's main dietary staple, the relationship of maize intake to serum AFB₁-albumin adducts levels in Guatemala has not been previously examined. As a result, a cross-sectional study was conducted among 461 Guatemalan adults living in five geographically distinct departments of the country. Participants provided a serum sample and completed a semi-quantitative food frequency questionnaire and a sociodemographic questionnaire. Multiple linear regression analysis was used to estimate the least square means (LSQ) and 95% confidence intervals (95% CI) of log-transformed AFB₁-albumin adducts by quintiles of maize consumption in crude and adjusted models. Additionally, analyses of tortilla consumption and levels of maize processing were conducted. The median maize intake was 344.3 g per day [Interquartile Range (IQR): 252.2, 500.8], and the median serum AFB₁-albumin adduct level was 8.4 pg/mg albumin (IQR: 3.8, 22.3). In adjusted analyses, there was no association between overall maize consumption and serum AFB₁-albumin levels. However, there was a statistically significant association between tortilla consumption and AFB₁-albumin levels (p_trend = 0.01). The LSM of AFB₁-albumin was higher in the highest quintile of tortilla consumption compared to the lowest quintile [LSM:9.03 95%CI: 7.03,11.70 vs 6.23, 95%CI: 4.95,8.17, respectively]. These findings indicate that tortilla may be an important source of AFB₁ exposure in the Guatemalan population. Therefore, efforts to control or mitigate AFB₁ levels in contaminated maize used for tortillas may reduce overall exposure in this population.

Effects of protocol-based management on the post-operative outcome after systemic to pulmonary shunt

Objectives

Systemic to pulmonary shunt (commonly known as Modified Blalock-Taussig shunt) is a palliative procedure in cyanotic heart diseases to overcome inadequate blood flow to the lungs. Based on the most recent risk stratification score, the mortality and morbidity of this procedure is still high especially in neonates and over-shunting patients. We developed and implemented protocol-based management in March 2013 to better standardize the management of these patients. The aim of this study is to evaluate the effects of applying this protocol-based management in our center.

Methods

We conducted a retrospective cohort study through chart review analysis.We included all children who underwent MBTS from January 2000 till December 2015. We compared the early postoperative outcome of patients operated after the protocol-based management implementation (March 2013 till December 2015) (protocol group) with patients operated before implementing the MBTS protocoled management (control group).

Results

197 patients underwent MBTS from January 2000 till December 2015. Of the 197 patients, 25 patients were in the protocol group and 172 patients were in the control group. There was a significant improvement in the postoperative course and less morbidity after protocoled management implementation as reflected in ventilation time, reintubation rate, inotropic support duration, intensive care unit ICU stay and significantly lower postoperative complications in the protocol group. Mortality of the control group versus protocol group (19.3% VS 8%) with Standardized Mortality Ratio (SMR) dropped from 2.27 before protocoled management to 0.94 after protocoled management (protocol group).

Conclusion

The study suggests that protocoled management of patients with MBTS can improve the postoperative course and early outcome.

Needs Assessment for Weight Management: The Learning Health System Network Experience

Objective

To assess patients' weight management needs and experiences across multiple sites within the Learning Health System Network.

Patients and Methods

A total of 19,964 surveys were sent to patients identified with overweight or obesity through medical record query at 5 health care systems throughout 11 states. The survey collected patients' experiences with and opinions about weight management in clinical care from October 27, 2017, through March 1, 2018.

Results

Among the 2380 responders, being younger, female, nonwhite, and single and having some college education or less were all significantly associated with higher body mass index (BMI). The most frequent weight loss barriers included food cravings (30.7%-49.9%) and having a medical condition limiting physical activity (17.7%-47.1%) (P<.001). Higher BMI was associated with a higher frequency of comorbidities and lower health status (P<.001). Higher BMI was also associated with a higher belief that primary care providers (PCPs) should be involved in weight loss management (P=.01) but lower belief that the PCP had the necessary skills and knowledge to help (P<.001). Responders with a higher BMI were more likely to feel judged (P<.001) and not always respected (P<.001) by their PCP. In addition, those with a higher BMI more frequently reported avoiding health care visits because of weight gain, not wanting to undress or be weighed, and not wanting to discuss their weight with their PCP (P<.001).

Conclusion

Physician involvement in weight management is important to patients whose needs and experiences differ by BMI. These data may inform clinical weight management efforts and create greater alignment with patient expectations.

Expanded Patient Access to Investigational New Devices: Review of Emergency and Nonemergency Expanded Use, Custom, and 3D-Printed Devices

U.S. Food and Drug Administration (FDA) approval of Class III medical devices can take from 3 to 7 years. Although this is shorter than times for drug approvals, patients with serious or life-threatening diseases and disorders may not have time to wait for device approval to access needed treatments. The FDA has a number of pathways, similar to drug approval processes, for expanded use of unapproved medical devices in patients for whom no reasonable alternative therapy is available. Additionally, the FDA regulates the manufacture and use of "custom" medical devices-those made for use by 1 specific patient. With the advent of 3-dimensional printing and bioprinting, new rules are evolving to address concerns that lines may be blurred between "custom" treatments and unregulated human experimentation.

Expanding Patient Access to Investigational Drugs: Single Patient Investigational New Drug and the "Right to Try"

With drug approval times taking an average of 8 years from entry into clinical trials to full U.S. Food and Drug Administration (FDA) approval, patients with life-threatening and severely debilitating disease and no reasonable therapeutic options are advocating for expanded access (EA) to investigational drugs prior to approval. Special investigational new drug (IND) application categories allow patients who meet specific criteria to receive treatment with non-approved drugs. The FDA approves over 99% of all single-patient INDs, providing emergency approval within hours, and non-emergency approval within an average of 4 days. "Right-to-try" laws passed in 38 states would allow patients to bypass FDA processes altogether, but contain controversial provisions that some claim risk more harm than benefit to desperate and vulnerable patients. This review focuses on FDA EA to non-approved drugs through a special category of IND-the single-patient IND-and "right-to-try" (R2T) access outside of the FDA.

Evaluation of striatonigral connectivity using probabilistic tractography in Parkinson's disease

The cardinal movement abnormalities of Parkinson's disease (PD), including tremor, muscle rigidity, and reduced speed and frequency of movements, are caused by degeneration of dopaminergic neurons in the substantia nigra that project to the putamen, compromising information flow through frontal-subcortical circuits. Typically, the nigrostriatal pathway is more severely affected on the side of the brain opposite (contralateral) to the side of the body that manifests initial symptoms. Several studies have suggested that PD is also associated with changes in white matter microstructural integrity. The goal of the present study was to further develop methods for measuring striatonigral connectivity differences between PD patients and age-matched controls using diffusion weighted magnetic resonance imaging (MRI).

In this cross-sectional study, 40 PD patients and 44 controls underwent diffusion weighted imaging (DWI) using a 40-direction MRI sequence as well as an optimized 60-direction sequence with overlapping slices. Regions of interest (ROIs) encompassing the putamen and substantia nigra were hand drawn in the space of the 40-direction data using high-contrast structural images and then coregistered to the 60-direction data. Probabilistic tractography was performed in the native space of each dataset by seeding the putamen ROI with an ipsilateral substantia nigra classification target. The effect of disease group (PD versus control) on mean putamen-SN connection probability and streamline density were then analyzed using generalized linear models controlling for age, gender, education, as well as seed and target region characteristics.

Mean putamen-SN streamline density was lower in PD on both sides of the brain and in both 40- and 60-direction data. The optimized sequence provided a greater separation between PD and control means; however, individual values overlapped between groups. The 60-direction data also yielded mean connection probability values either trending (ipsilateral) or significantly (contralateral) lower in the PD group. There were minor between-group differences in average diffusion measures within the substantia nigra ROIs that did not affect the results of the GLM analyses when included as covariates. Based on these results, we conclude that mean striatonigral structural connectivity differs between PD and control groups and that use of an optimized 60-direction DWI sequence with overlapping slices increases the sensitivity of the technique to putative disease-related differences. However, overlap in individual values between disease groups limits its use as a classifier.

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The nigrostriatal pathway degenerates in Parkinson's disease.

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Two diffusion tensor imaging (DTI) sequences were acquired in 84 participants.

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Structural connectivity between putamen and substantia nigra was quantified.

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Parkinson's patients had lower connection probability and streamline density.

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A 60-direction DTI sequence with overlapping slices was most sensitive.

Experience and Outcomes at a Specialized Clostridium difficile Clinical Practice

Objective

To report our experience with and outcomes among patients referred to a specialized Clostridium difficile clinical practice.

Patients and Methods

We retrospectively identified consecutive patients referred for Clostridium difficile infection (CDI) management from January 1, 2013, through May 30, 2015. Data were collected for demographic characteristics, CDI history, final diagnoses, and management.

Results

Overall, 211 patients (median age, 65 years; 66.4% women) were included. The most common indications for referral were recurrent CDI in 199 patients (94.3%), first CDI episode in 5 patients (2.4%), and chronic diarrhea in 7 patients (3.3%). After evaluation, the diagnoses were recurrent CDI in 127 patients (60.2%), resolved CDI in 36 patients (17.1%), first-episode CDI in 5 patients (2.4%), and non-CDI in 43 patients (20.4%). The most common non-CDI diagnoses were postinfection irritable bowel syndrome (PI-IBS) in 32 patients (15.2% overall), inflammatory bowel disease (n=3), small intestinal bacterial overgrowth (n=2), microscopic colitis (n=1), and asymptomatic C difficile colonization (n=2). Two patients had diabetic gastroparesis and food intolerances, and 1 had chronic constipation with overflow diarrhea. Of 127 patients with recurrent CDI, 30 (23.6%) received antibiotics; of these 30, 12 had antibiotic treatment failure and received fecal microbiota transplantation (FMT) for recurrent CDI. Among 97 patients (76.4%) who underwent FMT, 85 (87.6%) were cured after the first FMT, 5 were cured after the second FMT, and 7 were treated with antibiotics for FMT failure, with resolution of symptoms.

Conclusion

A substantial proportion of patients referred for CDI subsequently received alternative diagnoses; PI-IBS was the most common. Patients being referred for recurrent CDI should be evaluated carefully for alternative diagnoses.

Drugs, Devices, and the FDA: Part 2: An Overview of Approval Processes: FDA Approval of Medical Devices

As with new drugs, the U.S. Food and Drug Administration’s approval process is intended to provide consumers with assurance that, once it reaches the market place, a medical device is safe and effective in its intended use. Bringing a device to market takes an average of 3 to 7 years, compared with an average of 12 years for drugs. However, there are concerns that Food and Drug Administration processes may not be sufficient to meet the assurances of safety and efficacy as intended. This second part of a 2-part series reviews the basic steps in development and Food and Drug Administration approval of medical devices, and summarizes post-marketing processes for drugs and devices.

P-glycoprotein Mediates Ceritinib Resistance in Anaplastic Lymphoma Kinase-rearranged Non-small Cell Lung Cancer

The anaplastic lymphoma kinase (ALK) fusion oncogene is observed in 3%–5% of non-small cell lung cancer (NSCLC). Crizotinib and ceritinib, a next-generation ALK tyrosine kinase inhibitor (TKI) active against crizotinib-refractory patients, are clinically available for the treatment of ALK-rearranged NSCLC patients, and multiple next-generation ALK-TKIs are currently under clinical evaluation. These ALK-TKIs exhibit robust clinical activity in ALK-rearranged NSCLC patients; however, the emergence of ALK-TKI resistance restricts the therapeutic effect. To date, various secondary mutations or bypass pathway activation-mediated resistance have been identified, but large parts of the resistance mechanism are yet to be identified. Here, we report the discovery of p-glycoprotein (P-gp/ABCB1) overexpression as a ceritinib resistance mechanism in ALK-rearranged NSCLC patients. P-gp exported ceritinib and its overexpression conferred ceritinib and crizotinib resistance, but not to PF-06463922 or alectinib, which are next-generation ALK inhibitors. Knockdown of ABCB1 or P-gp inhibitors sensitizes the patient-derived cancer cells to ceritinib, in vitro and in vivo. P-gp overexpression was identified in three out of 11 cases with in ALK-rearranged crizotinib or ceritinib resistant NSCLC patients. Our study suggests that alectinib, PF-06463922, or P-gp inhibitor with ceritinib could overcome the ceritinib or crizotinib resistance mediated by P-gp overexpression.

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Ceritinib resistant patient-derived cancer cells overexpress P-gp without having mutation in ALK and other major oncogenes.

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P-gp overexpression conferred the resistance to ceritinib and crizotinib but not to alectinib and PF-06463922.

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Ceritinib is a substrate of P-gp, and P-gp-inhibitors or knockdown of P-gp reversed ceritinib resistance.

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P-gp overexpression was observed in 3 out of 11 crizotinib- or ceritinib-resistant ALK-rearranged NSCLC patients.

For treatment of ALK-rearranged NSCLC, two ALK-TKIs, crizotinib and ceritinib are currently in use, but the emergence of acquired resistance limits the efficacy of ALK-TKIs. Except for the resistance-associated mutations in ALK, ALK-TKIs resistance mechanisms are still largely unknown. Here we identified P-gp overexpression mediating resistance in three ceritinib-resistant ALK-rearranged NSCLC patients. P-gp overexpression conferred ceritinib and crizotinib resistance but did not confer alectinib and PF-06463922 resistance, and treatment using P-gp inhibitor with ceritinib, or alectinib- or PF-06463922- monotherapy overcame the resistance, suggesting that P-gp expression could be an important determinant in the future treatment strategies.

Quantitative T cell repertoire analysis by deep cDNA sequencing of T cell receptor α and β chains using next-generation sequencing (NGS)

Immune responses play a critical role in various disease conditions including cancer and autoimmune diseases. However, to date, there has not been a rapid, sensitive, comprehensive, and quantitative analysis method to examine T-cell or B-cell immune responses. Here, we report a new approach to characterize T cell receptor (TCR) repertoire by sequencing millions of cDNA of TCR α and β chains in combination with a newly-developed algorithm. Using samples from lung cancer patients treated with cancer peptide vaccines as a model, we demonstrate that detailed information of the V-(D)-J combination along with complementary determining region 3 (CDR3) sequences can be determined. We identified extensive abnormal splicing of TCR transcripts in lung cancer samples, indicating the dysfunctional splicing machinery in T lymphocytes by prior chemotherapy. In addition, we found three potentially novel TCR exons that have not been described previously in the reference genome. This newly developed TCR NGS platform can be applied to better understand immune responses in many disease areas including immune disorders, allergies, and organ transplantations.

Chemokine and lymph node homing receptor expression on pDC vary by graft source

A randomized clinical trial of BM vs. blood stem cell transplants from unrelated donors showed that more plasmacytoid dendritic cells (pDCs) in BM grafts was associated with better post-transplant survival. Here, we describe differences in homing-receptor expression on pDC to explain observed differences following BM vs. blood stem cell transplantation.