Anencephaly in a triplet pregnancy: Unprecedented spontaneous reabsorption in-utero and subsequent normal delivery via c-section: A rare case report

Multiple pregnancies are infrequently encountered, with the incidence of spontaneous triplet pregnancies estimated at approximately 1 in 7000 pregnancies. Triplet gestations are recognized for their propensity to bring about a spectrum of pregnancy related complexities, encompassing fetal structural abnormalities, neurological anomalies, disturbances in amniotic fluid levels, preterm labor, and suboptimal neonatal outcomes. Anencephaly is a serious congenital defect where the brain and skull do not fully develop, often leading to a poor prognosis. It's a preventable neural tube defect (NTD) with timely intake of folic acid, is caused by the incomplete closure of the neural tube during fetal development, resulting in the absence of the cerebrum (responsible for thinking and coordination) and the front part of the brain (forebrain) in affected infants. While anencephaly in a triplet is scarcely reported, spontaneous reabsorption of an anencephalic fetus in utero is a rare and unexpected event, with no documented cases in triplet pregnancies until now. We report a case of anencephaly in a triplet pregnancy where the mother presented late during her third trimester, the reabsorption of the anencephalic fetus in utero is an unprecedented event, highlighting the unique nature of this triplet pregnancy.

Comparative analysis of risk factors for retinopathy of prematurity in single and multiple birth neonates

AIM

To conduct a comparative analysis of risk factors for retinopathy of prematurity (ROP) in single- and multiple-born neonates.

METHODS

In a retrospective evaluation of 521 premature neonates, encompassing singletons, twins, and triplets born at or before 34 weeks of gestational age with a birthweight of less than 2000 g and who completed the ROP screening program, between 2020 and 2023, in outpatient referral ROP screening clinic affiliated by Shiraz University of Medical Sciences, were included. Neonates with the eligibility criteria were enrolled in the screening program from 28 days old age and followed up to discharge or treatment based on national ROP screening guideline. Data on ROP severity, outcome, treatment modality, and risk factors, including gestational age (GA), birth weight (BW), sex, duration of neonatal intensive care unit (NICU) admission, oxygen supplementation, mechanical ventilation, blood transfusion, method of delivery, and maternal and neonatal comorbidities, were extracted and compared between premature neonates from singleton and multiple births.

RESULTS

The analysis of the ROP severity distribution revealed 238 neonates (45.7%) with low-risk (type 2 prethreshold ROP or less severe) ROP and 16 (3.1%) with high-risk (type I prethreshold ROP or more severe) ROP who underwent treatment. According to the comparative analysis of risk factors in neonates with ROP requiring treatment, multiple birth neonates exhibited significantly greater GA (27.50 ± 3.27 vs. 30.00 ± 2.00 vs. 31.14 ± 0.38 weeks, p = 0.032 for singletons, twins and triplets, respectively); greater BW (861.67 ± 274.62 vs. 1233.33 ± 347.75 vs. 1537.14 ± 208.86 g, p = 0.002); and shorter duration of NICU admission (60.17 ± 21.36 vs. 34.00 ± 12.17 vs. 12.00 ± 6.32 days, p = 0.001) and oxygen supplementation (47.33 ± 16.57 vs. 36.00 ± 8.49 vs. 4.60 ± 2.41 days, p = 0.001). There was no significant difference between single-born neonates and multiple-born neonates regarding the prevalence of other risk factors. Multiple-born neonates with no ROP and low risk ROP showed significantly lower GA and BW compared to singletons (p < 0.001).

CONCLUSION

Multiple gestation neonates may develop high-risk ROP requiring treatment at a greater gestational age and birth weight and at a lower duration of oxygen supplementation and NICU admission compared to the single birth neonates. This pattern prompts a reevaluation of screening criteria, suggesting a potential need to consider multiple birth neonates with lower traditional risk factors in screening programs. This pattern should be further evaluated in larger populations of multiple born premature neonates.

Selinexor-Based Triplet Regimens in Patients With Multiple Myeloma Previously Treated With Anti-CD38 Monoclonal Antibodies

BACKGROUND

The increasing use of anti-CD38 monoclonal antibodies (αCD38 mAbs) for newly diagnosed or early relapsed multiple myeloma (MM), especially in non-transplant eligible patients, may lead to more patients developing αCD38 mAb-refractory disease earlier in the treatment course with fewer treatment options.

PATIENTS AND METHODS

We analyzed the efficacy and safety of selinexor-based triplets (selinexor+dexamethasone [Sd] plus pomalidomide [SPd, n = 23], bortezomib [SVd, n = 16] or carfilzomib (SKd, n = 23]) in a subset of STOMP (NCT02343042) and BOSTON (NCT03110562) study patients treated previously with αCD38 mAbs.

RESULTS

Sixty-two patients (median 4 prior therapies, range 1 to 11, 90.3% refractory to αCD38 mAb) were included. Overall response rates (ORR) in the SPd, SVd and SKd cohorts were 52.2%, 56.3%, and 65.2%, respectively. Overall response rate was 47.4% among patients who had MM refractory to the third drug reintroduced in the Sd-based triplet. Median progression-free survival in the SPd, SVd, and SKd cohorts was 8.7, 6.7, and 15.0 months, respectively, and median overall survival was 9.6, 16.9, and 33.0 months, respectively. Median time to discontinuation in the SPd, SVd, and SKd cohorts was 4.4, 5.9, and 10.6 months, respectively. The most common hematological adverse events were thrombocytopenia, anemia, and neutropenia. Nausea, fatigue, and diarrhea were primarily grade 1/2. Adverse events were generally manageable with standard supportive care and dose modifications.

CONCLUSION

Selinexor-based regimens may offer effective and well-tolerated therapy to patients with relapsed and/or refractory MM who had disease previously exposed or refractory to αCD38 mAb therapy and could help address the unmet clinical need in these high-risk patients.

Advantage of achieving deep response following frontline daratumumab-VTd compared to VRd in transplant-eligible multiple myeloma: multicenter study

Background

The goal of induction therapy for multiple myeloma (MM) is to achieve adequate disease control. Current guidelines favor triplet (bortezomib-lenalidomide-dexamethasone; VRd) or quadruplet regimens (daratumumab, bortezomib-thalidomide-dexamethasone; D-VTd). In the absence of a direct comparison between two treatment regimens, we conducted this study to compare the outcomes and safety of VRd and D-VTd.

Methods

Newly diagnosed MM patients aged >18 years who underwent induction therapy followed by autologous stem cell transplantation (ASCT) between November 2020 and December 2021 were identified. Finally, patients with VRd (N=37) and those with D-VTd (N=43) were enrolled.

Results

After induction, 10.8% of the VRd group showed stringent complete remission (sCR), 21.6% showed complete response (CR), 35.1% showed very good partial response (VGPR), and 32.4% showed partial response (PR). Of the D-VTd group, 9.3% showed sCR, 34.9% CR, 48.8% VGPR, and 4.2% PR (VGPR or better: 67.6% in VRd vs. 93% in D-VTd, P=0.004). After ASCT, 68.6% of the VRd group showed CR or sCR, while 90.5% of the D-VTd group showed CR or sCR (P=0.016). VRd was associated with an increased incidence of skin rash (P=0.044). Other than rashes, there were no significant differences in terms of adverse events between the two groups.

Conclusion

Our study supports the use of a front-line quadruplet induction regimen containing a CD38 monoclonal antibody for transplant-eligible patients with newly diagnosed MM.

[A retrospective analysis of 124 patients with multiple myeloma who received up-front autologous hematopoietic cell transplantation following triplet induction therapy]

The IFM/DFCI group reported that VRD induction followed by up-front autologous peripheral blood stem cell transplantation (ASCT) and maintenance therapy led to median PFS of 50 months, which established up-front ASCT as the standard of care even in the era of novel agents. We conducted a retrospective analysis on outcomes of patients who received triplet induction therapy followed by up-front ASCT at our institution. A total of 124 patients received ASCT between November 2016 and December 2021 at Japanese Red Cross Medical Center. Patient characteristics, treatment response before and after ASCT, and PFS and OS were retrospectively analyzed. VRD-based induction therapy was used for 94%. Among 118 evaluable patients, 116 (98%) received either consolidation and/or maintenance therapy. Best responses were ≥CR 77% and ≥VGPR 94%, respectively. Sixty-eight out of 104 patients achieved MRD-negativity by multiparameter FCM (<10-5). Five-year estimated PFS and OS were 54.7% and 80.2%, respectively. Age ≥65, high-risk cytogenetic abnormalities, and Collapse

Key Words

• Autologous peripheral blood stem cell transplantation
• Melphalan
• Multiple myeloma
• Triplet

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MESH Headings

• Humans
• Antineoplastic Combined Chemotherapy Protocols
• Bortezomib/therapeutic use
• Hematopoietic Stem Cell Transplantation
• Induction Chemotherapy
• Multiple Myeloma/drug therapy
• Prospective Studies
• Retrospective Studies
• Transplantation, Autologous
• Treatment Outcome
• Aged

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Grants Collapse

Affiliation(s)

Nobuhiro Tsukada Department of Hematology, Japanese Red Cross Medical Center
Yuki Oda Department of Hematology, Japanese Red Cross Medical Center
Moe Nomura Department of Hematology, Japanese Red Cross Medical Center
Yuki Kasuya Department of Hematology, Japanese Red Cross Medical Center
Tomomi Takei Department of Hematology, Japanese Red Cross Medical Center
Kota Sato Department of Hematology, Japanese Red Cross Medical Center
Mizuki Ogura Department of Hematology, Japanese Red Cross Medical Center
Taku Kikuchi Department of Hematology, Japanese Red Cross Medical Center
Yu Abe Department of Hematology, Japanese Red Cross Medical Center
Kenshi Suzuki Department of Hematology, Japanese Red Cross Medical Center
Tadao Ishida Department of Hematology, Japanese Red Cross Medical Center

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Fetoscopic laser surgery for twin-to-twin transfusion syndrome in DCTA triplets compared to MCDA twins: collaborative study and literature review

OBJECTIVE

To compare the outcomes of dichorionic triamniotic (DCTA) triplets with that of monochorionic diamniotic (MCDA) twin gestations undergoing fetoscopic laser surgery (FLS) for treatment of twin-to-twin transfusion syndrome (TTTS).

METHODS

Retrospective cohort study of prospectively collected data of consecutive DCTA triplet and MCDA twin pregnancies with TTTS that underwent FLS at two fetal treatment centers between 2012 and 2020. Preoperative, operative and, postoperative variables were collected. Perinatal outcomes were investigated. Primary outcome was survival to birth and to neonatal period. Secondary outcomes were gestational age (GA) at birth and procedure-to-delivery interval. Literature review was conducted in which PubMed, Web of Science, and Scopus were searched from inception to September, 2020.

RESULTS

Twenty four sets of DCTA triplets were compared to MCDA twins during the study period. There were no significant differences in survival (no survivor, single, or double survivors) to birth and to the neonatal period of the MC twin pairs of the DCTA triplets vs MCDA twins. Median GA at delivery was approximately three weeks earlier in DCTA triplets compared to MCDA twins (28.4 weeks vs 31.4 weeks, p = .035, respectively). Rates of preterm birth (PTB) less than 32 and less than 28 weeks were significantly higher in DCTA triplets compared to twins (<32 weeks: 70.8% vs 51.1%, p = .037, respectively, and <28 weeks: 37.5% vs 20.8%, p = .033, respectively).

CONCLUSION

Perinatal survival including fetal and neonatal are comparable between DCTA triplets and MCDA twins. However, this might have resulted from the small sample size of the DCTA triplets. GA at delivery is earlier in triplets, which could be due to the nature of triplet gestation rather than to the laser procedure itself.

WJOG13219G: The Efficacy and Safety of FOLFOXIRI or Doublet plus Anti-VEGF Therapy in Previously Untreated BRAFV600E Mutant Metastatic Colorectal Cancer: A Multi-Institutional Registry-Based Study (BRACELET Study)

BACKGROUND

The real-world survival benefit of FOLFOXIRI (fluorouracil, leucovorin, oxaliplatin, and irinotecan) plus anti-VEGF therapy (Triplet) over doublet chemotherapy (Doublet) remains controversial in patients with BRAF^V600E mutant metastatic colorectal cancer (mCRC).

PATIENTS AND METHODS

WJOG13219G was a multicenter, retrospective, registry-based study of patients with BRAF^V600E mutant mCRC who received first-line triplet or doublet chemotherapy from January 2014 to December 2019 in Japan. Inverse probability of treatment weighting (IPTW) was used to adjust for patient background.

RESULTS

The analysis included 79 and 91 patients in the Triplet and Doublet groups, respectively. The Triplet group was significantly younger and had better performance status. No statistical difference was noted in progression-free survival (PFS; HR, 0.82; 95% CI, 0.60-1.13; P = .22) and overall survival (OS; HR, 0.88; 95% CI, 0.62-1.25; P = .48) between both groups. IPTW analysis also showed no difference between the 2 groups in PFS (HR, 0.86; 95% CI, 0.69-1.08; P = .20) and OS (HR, 0.93; 95% CI, 0.73-1.20; P = .59). The Triplet and Doublet groups had an objective response rate of 53% and 41%, respectively (P = .10). At least one grade 3 or 4 adverse event was seen in 51 (65%) and 43 (47%) patients in the Triplet and Doublet groups, respectively, with the incidence of neutropenia being significantly higher in the former.

CONCLUSION

Triplet therapy had no survival benefit versus doublet therapy in the overall and IPTW cohorts or specific subgroups for real-world patients with BRAF^V600E mutant mCRC.

Structural and Electronic (Absorption and Fluorescence) Properties of a Stable Triplet Diphenylcarbene: A DFT Study

A triplet diphenylcarbene, bis[3-bromo-5-(trifluoromethyl)[1,1'-biphenyl]-4-yl]methylidene (B3B), with exceptional stability was discovered by chemists from Japan's Mie University. To investigate its different quantum chemical features, a theoretical analysis was predicated on Density Functional Theory (DFT) and Time Dependent-DFT (TD-DFT) based technique. According to the findings, the singlet-triplet energy gap (ES-T), as well as HOMO-LUMO energy bandgap (E_H-L), was found to be diminished when nucleophilicity (N) rose. We looked at the geometrical dimensions, molecular orbitals (MOs), electronic spectra, electrostatic potential, molecular surfaces, reactivity characteristics, and thermodynamics features of the title carbene (B3B). Its electronic spectra in different solvents were calculated using TD-DFT and Polarizable Continuum Model (PCM) framework. The estimated absorption maxima of B3B were seen between 327 and 340 nm, relying on the solvents, and were attributed to the S⁰ → S¹ transition. Estimated fluorescence spectral peaks were found around 389 and 407 nm with the S¹ and S⁰ transitions being identified. Its fluorescence/absorption intensities revealed a blue shift change when the solvent polarity was increased. The least exciting state has been discovered to be the π → π^* charge-transfer (CT) phase. According to the Natural Bonding Orbital (NBO) exploration, ICT offers a significant role in chemical system destabilization. Furthermore, several hybrid features were used to determine the NLO (nonlinear optical) features (polarizability, first-order hyperpolarizability, and dipole moment). The calculated values suggest that B3B is a promising candidate for further research into nonlinear optical properties.

Pure Boric Acid Does Not Show Room-Temperature Phosphorescence (RTP)

Boric acid (BA) has been used as a transparent glass matrix for optical materials for over 100 years. However, recently, apparent room‐temperature phosphorescence (RTP) from BA (crystalline and powder states) was reported (Zheng et al., Angew. Chem. Int. Ed. 2021, 60, 9500) when irradiated at 280 nm under ambient conditions. We suspected that RTP from their BA sample was induced by an unidentified impurity. Our experimental results show that pure BA synthesized from B(OMe)₃ does not luminesce in the solid state when irradiated at 250–400 nm, while commercial BA indeed (faintly) luminesces. Our theoretical calculations show that neither individual BA molecules nor aggregates would absorb light at >175 nm, and we observe no absorption of solid pure BA experimentally at >200 nm. Therefore, it is not possible for pure BA to be excited at >250 nm even in the solid state. Thus, pure BA does not display RTP, whereas trace impurities can induce RTP.

Comparing ultrafast excited state quenching of flavin 1,N6-ethenoadenine dinucleotide and flavin adenine dinucleotide by optical spectroscopy and DFT calculations

Flavins are photoenzymatic cofactors often exploiting the absorption of light to energize photoinduced redox chemistry in a variety of contexts. Both flavin adenine dinucleotide (FAD) and flavin mononucleotide (FMN) are used for this function. The study of these photoenzymes has been facilitated using flavin analogs. Most of these analogs involve modification of the flavin ring, and there is recent evidence that adenine (Ade)-modified FAD can affect enzyme turnover, but so far this has only been shown for enzymes where the adenine and flavin rings are close to each other in a stacked conformation. FAD is also stacked in aqueous solution, and its photodynamics are quite different from unstacked FAD or FMN. Oxidized photoexcited FAD decays rapidly, presumably through PET with Ade as donor and Fl* as acceptor. Definitive identification of the spectral signatures of Ade^∙+ and Fl^∙- radicals is elusive. Here we use the FAD analog Flavin 1,N⁶-Ethenoadenine Dinucleotide (εFAD) to study how different photochemical outcomes depend on the identity of the Ade moiety in stacked FAD and its analog εFAD. We have used UV-Vis transient absorption spectroscopy complemented by TD-DFT calculations to investigate the excited state evolution of the flavins. In FAD*, no radicals were observed, suggesting that FAD* does not undergo PET. εFAD* kinetics showed a broad absorption band that suggests a charge transfer state exists upon photoexcitation with evidence for radical pair formation. Surprisingly, significant triplet flavin was produced from εFAD* We hypothesize that the dipolar (ε)Ade moieties differentially modulate the singlet-triplet energy gap, resulting in different intersystem crossing rates. The additional electron density on the etheno group of εFAD supplies better orbital overlap with the flavin S₁ state, accelerating charge transfer in that molecule.

Estimates of voluntary activation in individuals with anterior cruciate ligament reconstruction: Effects of type of stimulator, number of stimuli, and quantification technique

BACKGROUND

Accurate quantification of voluntary activation is important for understanding the extent of quadriceps dysfunction in individuals with anterior cruciate ligament reconstruction (ACLR). Voluntary activation has been quantified using both percent activation derived from the interpolated twitch technique and central activation ratio (CAR) derived from the burst superimposition technique, as well as by using different types of electrical stimulators and pulse train conditions. However, it is unclear how these parameters affect voluntary activation estimates in individuals with ACLR. This study was performed to fill this important knowledge gap in the anterior cruciate ligament literature.

METHODS

Quadriceps strength and voluntary activation were examined in 18 ACLR participants (12 quadriceps/patellar tendon graft, 6 hamstring tendon graft; time since ACLR: 1.06 ± 0.82 years, mean ±  SD) at 90° of knee flexion using 2 stimulators (Digitimer and Grass) and pulse train conditions (3-pulse and 10-pulse). Voluntary activation was quantified by calculating both CAR and percent activation.

RESULTS

Results indicated that voluntary activation was significantly overestimated by CAR when compared with percent activation (p < 0.001). Voluntary activation estimates were not affected by pulse train conditions when using percent activation; however, 3-pulse stimuli resulted in greater overestimation than 10-pulse stimuli when using CAR (p = 0.003). Voluntary activation did not differ between stimulators (p > 0.05); however, the Digitimer evoked greater torque at rest than the Grass (p < 0.001).

CONCLUSION

These results indicate that percent activation derived from the interpolated twitch technique provides superior estimates of voluntary activation than CAR derived from burst superimposition and is less affected by pulse train conditions or stimulators in individuals with ACLR.

Combination therapy of capecitabine, irinotecan, oxaliplatin, and bevacizumab as a first-line treatment for metastatic colorectal cancer: Safety lead-in results from the QUATTRO-II study

Background FOLFOXIRI plus bevacizumab is the first-line treatment for metastatic colorectal cancer (mCRC) but demonstrates high neutropenia incidence among Asian patients. Hence, we conducted the randomized phase II QUATTRO-II study (ClinicalTrials.gov identifier: NCT04097444; Japan Registry of Clinical Trials identifier: jRTCs041190072) to evaluate the safety and efficacy of capecitabine, oxaliplatin, and irinotecan (CAPOXIRI) combination plus bevacizumab versus FOLFOXIRI plus bevacizumab, expecting a lower incidence of neutropenia without compromising the efficacy. Methods We investigated the recommended doses (RD) of oxaliplatin and irinotecan as a safety lead-in portion of Step 1 before initiating the randomized portion as Step 2. Four dose levels of CAPOXIRI (fixed dose of capecitabine, 1600 mg/m²; escalated/de-escalated doses of oxaliplatin and irinotecan) plus bevacizumab (7.5 mg/kg) were investigated in a 3 + 3 manner. A dose level of ≤ 2/6 of dose-limiting toxicity (DLT) cases was expected as the RD. Results In Step 1, we included nine patients (three and six in levels 0 and + 1, respectively). Level 0 (irinotecan, 200 mg/m²; oxaliplatin, 100 mg/m²) did not demonstrate DLTs. In level + 1 (irinotecan, 200 mg/m²; oxaliplatin, 130 mg/m²), although one patient experienced grade 4 febrile neutropenia, no further safety concerns were observed. As a preliminary efficacy result, the objective response rate in all nine patients was 89 % (100 and 83 % in levels 0 and + 1, respectively). Conclusions The RD of CAPOXIRI plus bevacizumab was 200, 130, and 1600 mg/m² for irinotecan, oxaliplatin, and capecitabine, respectively, and 7.5 mg/kg for bevacizumab. The randomized portion is still ongoing.

On the origin of the genetic code: a 27-codon hypothetical precursor of an intricate 64-codon intermediate shaped the modern code

The modern genetic code reveals numerous traces of specific relationships between the early codons which, together with its internal asymmetries, suggest a sequential appearance of the nucleobases in primitive RNA molecules. Keeping the hypothesis of triplet pairings between primitive RNA molecules at the origin of the code, this work systematically examines complete codon-anticodon interaction matrices assuming distinct pairing options at each position of the triplet duplexes. Application of these principles suggests that a 27-codon precursor having a reasonable coding capacity for short peptide synthesis could have started with primitive RNA molecules able to form two distinct pairs with different free energies between a single purine and two pyrimidines (such as G with C and U). Conservation of the same pairing options at positions 1 and 2 of codons at the arrival of a second purine with distinct pairing preferences (such as A) generated a 64-codon intermediate code made of interrelated pairs or groups of codons (designated here as intricacy). The numerous traces of this hypothetical scheme that are visible in the standard and variant forms of the modern code demonstrate without ambiguity that the ancestral codon-anticodon duplexes required high energetic pairings at their central position (Watson-Crick) but tolerated less energetic pairings at the first codon position (G • U type). Combined with the sequential appearance of the nucleobases, the predicted codon intricacy allows a stepwise reconstruction of the evolution of the coding repertoire, by simple a posteriori comparison to the modern code. This reconstruction reveals a remarkable internal coherence in terms of amino acids and tRNA synthetases recruitment. The code started with a group of amino acids (Ala, Gly, Pro, Ser and Thr) that are now all activated by class II tRNA synthetases before reaching an intermediate period during which up to 14 distinct amino acids could be encoded by a full set of intricated codons. The perfect coincidence between the last 6 amino acids predicted in this reconstruction and the speculated action of the arrival of free atmospheric oxygen on proteins is spectacular, and suggests that the code has only reached its present form after the great oxidation event.

Relating molecular descriptors to frontier orbital energy levels, singlet and triplet excited states of fused tricyclics using machine learning

Fused tricyclic organic compounds are an important class of organic electronic materials. In designing molecules for organic electronics, knowing what chemical structure that be used to tune the molecular property is one of the keys that can help to improve the material performance. In this research, we applied machine learning and data analytic approaches in addressing this problem. The energy states (Lowest Unoccupied Molecular Orbital (HOMO), Highest Occupied Molecular Orbitals (LUMO), singlet (E_s) and triplet (E_T) energy) of more than 10 thousand fused tricyclics are calculated. Corresponding descriptors are also generated. We find that the Coulomb matrix is a poorer descriptor than high-level descriptors in a multilayer perceptron neural network. Correlations as high as 0.95 is obtained using a multilayer perceptron neural network with Mean Absolute Error as low as 0.08 eV. The descriptors that are important in tuning the energy levels are revealed using the Random Forest algorithm. Correlations of such descriptors are also plotted. We found that the higher the number of tertiary amines, the deeper are the HOMO and LUMO levels. The presence of NN in the aromatic rings can be used to tune the E_S. However, there is no single dominant descriptor that can be correlated with the E_T. A collection of descriptors is found to give a far better correlation with E_T. This research demonstrated that machine learning and data analytics in guiding how certain chemical substructures correlate with the molecule energy states.

MetricUNet: Synergistic image- and voxel-level learning for precise prostate segmentation via online sampling

Fully convolutional networks (FCNs), including UNet and VNet, are widely-used network architectures for semantic segmentation in recent studies. However, conventional FCN is typically trained by the cross-entropy or Dice loss, which only calculates the error between predictions and ground-truth labels for pixels individually. This often results in non-smooth neighborhoods in the predicted segmentation. This problem becomes more serious in CT prostate segmentation as CT images are usually of low tissue contrast. To address this problem, we propose a two-stage framework, with the first stage to quickly localize the prostate region, and the second stage to precisely segment the prostate by a multi-task UNet architecture. We introduce a novel online metric learning module through voxel-wise sampling in the multi-task network. Therefore, the proposed network has a dual-branch architecture that tackles two tasks: (1) a segmentation sub-network aiming to generate the prostate segmentation, and (2) a voxel-metric learning sub-network aiming to improve the quality of the learned feature space supervised by a metric loss. Specifically, the voxel-metric learning sub-network samples tuples (including triplets and pairs) in voxel-level through the intermediate feature maps. Unlike conventional deep metric learning methods that generate triplets or pairs in image-level before the training phase, our proposed voxel-wise tuples are sampled in an online manner and operated in an end-to-end fashion via multi-task learning. To evaluate the proposed method, we implement extensive experiments on a real CT image dataset consisting 339 patients. The ablation studies show that our method can effectively learn more representative voxel-level features compared with the conventional learning methods with cross-entropy or Dice loss. And the comparisons show that the proposed method outperforms the state-of-the-art methods by a reasonable margin.

Crick Wobble and Superwobble in Standard Genetic Code Evolution

Wobble coding is inevitable during evolution of the Standard Genetic Code (SGC). It ultimately splits half of NN U/C/A/G coding boxes with different assignments. Further, it contributes to pervasive SGC order by reinforcing close spacing for identical SGC assignments. But wobble cannot appear too soon, or it will inhibit encoding and more decisively, obstruct evolution of full coding tables. However, these prior results assumed Crick wobble, NN U/C and NN A/G, read by a single adaptor RNA. Superwobble translates NN U/C/A/G codons, using one adaptor RNA with an unmodified 5' anticodon U (appropriate to earliest coding) in modern mitochondria, plastids, and mycoplasma. Assuming the SGC was selected when evolving codes most resembled it, characteristics of the critical selection events can be calculated. For example, continuous superwobble infrequently evolves SGC-like coding tables. So, continuous superwobble is a very improbable origin hypothesis. In contrast, late-arising superwobble shares late Crick wobble's frequent resemblance to SGC order. Thus late superwobble is possible, but yields SGC-like assignments less frequently than late Crick wobble. Ancient coding ambiguity, most simply, arose from Crick wobble alone. This is consistent with SGC assignments to NAN codons.

Optimal Evolution of the Standard Genetic Code

The Standard Genetic Code (SGC) exists in every known organism on Earth. SGC evolution via early unique codon assignment, then later wobble, yields coding resembling the near-universal code. Below, later wobble is shown to also create an optimal route to accurate codon assignment. Time of optimal codon assignment matches the previously defined mean time for ordered coding, exhibiting ≥ 90% of SGC order. Accurate evolution is also accessible, sufficiently frequent to appear in populations of 10³ to 10⁴ codes. SGC-like coding capacity, code order, and accurate assignments therefore arise together, in one attainable evolutionary intermediate. Examples, which plausibly resemble coding at evolutionary domain separation, are characterized.

Evolution of the Standard Genetic Code

A near-universal Standard Genetic Code (SGC) implies a single origin for present Earth life. To study this unique event, I compute paths to the SGC, comparing different plausible histories. Notably, SGC-like coding emerges from traditional evolutionary mechanisms, and a superior route can be identified. To objectively measure evolution, progress values from 0 (random coding) to 1 (SGC-like) are defined: these measure fractions of random-code-to-SGC distance. Progress types are spacing/distance/delta Polar Requirement, detecting space between identical assignments/mutational distance to the SGC/chemical order, respectively. The coding system is based on selected RNAs performing aminoacyl-RNA synthetase reactions. Acceptor RNAs exhibit SGC-like Crick wobble; alternatively, non-wobbling triplets uniquely encode 20 amino acids/start/stop. Triplets acquire 22 functions by stereochemistry, selection, coevolution, or at random. Assignments also propagate to an assigned triplet’s neighborhood via single mutations, but can also decay. A vast code universe makes futile evolutionary paths plentiful. Thus, SGC evolution is critically sensitive to disorder from random assignments. Evolution also inevitably slows near coding completion. The SGC likely avoided these difficulties, and two suitable paths are compared. In late wobble, a majority of non-wobble assignments are made before wobble is adopted. In continuous wobble, a uniquely advantageous early intermediate yields an ordered SGC. Revised coding evolution (limited randomness, late wobble, concentration on amino acid encoding, chemically conservative coevolution with a chemically ordered elite) produces varied full codes with excellent joint progress values. A population of only 600 independent coding tables includes SGC-like members; a Bayesian path toward more accurate SGC evolution is available.

Multiple Myeloma-Effect of Induction Therapy on Transplant Outcomes

BACKGROUND

Patients with multiple myeloma (MM) aged ≤ 65 to 70 years, with a good Eastern Cooperative Oncology Group performance status and no major comorbid conditions, are considered potential candidates for autologous stem cell transplant (ASCT) and will be treated with novel agent-based induction therapy for 4 to 6 cycles before ASCT.

PATIENTS AND METHODS

We analyzed the data from 326 patients with MM who had received novel agent-based induction before ASCT at our center to evaluate the effect of induction therapy on ASCT response, stem cell mobilization, engraftment characteristics, and survival. The median age was 52 years (range, 29-72 years), 216 patients were men (66.3%), 32.7% had stage III using the Revised Multiple Myeloma International Staging System, and 15.8% had high-risk cytogenetics. Of the 326 patients, 75 (23.0%) had undergone ASCT in second remission after salvage therapy for relapse. Also, 194 patients (59.5%) had received doublet induction therapy and 132 (40.5%) had received triplet induction therapy.

RESULTS

Triplet-based induction therapy was superior to doublet-based therapy for response (95.4% vs. 84.02%; P < .003), stem cell mobilization (CD34⁺ ≥ 2 × 10⁶/kg; 88.6% vs. 76.8%; P < .005), and lower 100-day transplant-related mortality (P < .001). The ≥100 day post-ASCT overall response (97.4% vs. 91.7%; P = .124) and complete response (72.5% vs. 68.0%; P = .38) rates were similar. At a median follow-up of 62.5 months, the overall survival (97.5 months vs. 100.0 months; P = .606) and progression-free survival (54.5 months vs. 57 months; P = .515) were similar between the triplet and doublet induction groups.

CONCLUSION

An initial response (chemosensitivity) to induction therapy will prepare patients better for subsequent consolidation therapy and ASCT, leading to favorable outcomes.

AtezoTRIBE: a randomised phase II study of FOLFOXIRI plus bevacizumab alone or in combination with atezolizumab as initial therapy for patients with unresectable metastatic colorectal cancer

Background

Immune checkpoint inhibitors (ICIs) reported remarkable achievements in several solid tumours. However, in metastatic colorectal cancer (mCRC) promising results are limited to patients with deficient mismatch repair/microsatellite instability-high (dMMR/MSI-high) tumours due to their immune-enriched microenvironment. Combining cytotoxic agents and bevacizumab in mCRC with proficient mismatch repair/microsatellite stability (pMMR/MSS) could make ICIs efficacious by increasing the exposure of neoantigens, especially with highly active chemotherapy regimens, inducing immunogenic cell death, increasing the tumoral infiltration of CD8+ T-cells and reducing tumour-associated myeloid-derived suppressor cells. VEGF-blockade also plays an immunomodulatory role by inhibiting the expansion of T regulatory lymphocytes.

Consistently with this rationale, a phase Ib study combined the anti-PDL-1 atezolizumab with FOLFOX/bevacizumab as first-line treatment of mCRC, irrespective of microsatellite status, and reported interesting activity and efficacy results, without safety concerns.

Phase III trials led to identify FOLFOXIRI plus bevacizumab as an upfront therapeutic option in selected mCRC patients. Drawing from these considerations, the combination of atezolizumab with an intensified upfront treatment (FOLFOXIRI) and bevacizumab could be worthy of investigation.

Methods

AtezoTRIBE is a prospective, open label, phase II, comparative trial in which initially unresectable and previously untreated mCRC patients, irrespective of microsatellite status, are randomized in a 1:2 ratio to receive up to 8 cycles of FOLFOXIRI/bevacizumab alone or in combination with atezolizumab, followed by maintenance with bevacizumab plus 5-fluoruracil/leucovorin with or without atezolizumab according to treatment arm until disease progression. The primary endpoint is PFS. Assuming a median PFS of 12 months for standard arm, 201 patients should be randomized in a 1:2 ratio to detect a hazard ratio of 0.66 in favour of the experimental arm. A safety run-in phase including the first 6 patients enrolled in the FOLFOXIRI/bevacizumab/atezolizumab arm was planned, and no unexpected adverse events or severe toxicities were highlighted by the Safety Monitoring Committee.

Discussion

The AtezoTRIBE study aims at assessing whether the addition of atezolizumab to an intensified chemotherapy plus bevacizumab might be an efficacious upfront strategy for the treatment of mCRC, irrespective of the microsatellite status.

Trial registration

AtezoTRIBE is registered at Clinicaltrials.gov (NCT03721653), October 26th, 2018 and at EUDRACT (2017–000977-35), Februray 28th, 2017.

Amazing symmetrical clustering in chloroplast genomes

Background

Previously, a seven-cluster pattern claiming to be a universal one in bacterial genomes has been reported. Keeping in mind the most popular theory of chloroplast origin, we checked whether a similar pattern is observed in chloroplast genomes.

Results

Surprisingly, eight cluster structure has been found, for chloroplasts. The pattern observed for chloroplasts differs rather significantly, from bacterial one, and from that latter observed for cyanobacteria. The structure is provided by clustering of the fragments of equal length isolated within a genome so that each fragment is converted in triplet frequency dictionary with non-overlapping triplets with no gaps in frame tiling. The points in 63-dimensional space were clustered due to elastic map technique. The eight cluster found in chloroplasts comprises the fragments of a genome bearing tRNA genes and exhibiting excessively high GC-content, in comparison to the entire genome.

Conclusion

Chloroplasts exhibit very specific symmetry type in distribution of coding and non-coding fragments of a genome in the space of triplet frequencies: this is mirror symmetry. Cyanobacteria may have both mirror symmetry, and the rotational symmetry typical for other bacteria.

Behaviour of twin- and triplet-born lambs and their dam 3 to 18 hours after birth is not a useful predictor of lamb survival to weaning

Objective

An experiment was designed to determine if behaviour traits expressed by twin- and triplet-bearing lambs and their dams at 3 to 18 hours of age (after the immediate ewe-lamb bonding had occurred) were associated with lamb survival to weaning.

Methods

The behaviour of twin and triplet lambs and their dams was assessed in the paddock at 3 to 18 hours after birth. Observations were made of the number of high- and low-pitched bleats, time to stand, make contact with dam, suck from dam and follow dam were recorded for each lamb. The maternal behaviour score of each dam was assessed. A random sub-sample of lambs were assessed during a maternal-recognition test at 12 or 24 hours of age. Traits included time spent standing, sitting, walking, time taken to reach the ewes and time spent with the ewes as well as the number of high- and low-pitched bleats emitted by the lamb.

Results

In the paddock, for each additional second required for twin-born lambs to follow their dam, lambs were 1.004 (95% confidence interval [CI] 1.000 to 1.008) times more likely to survive to weaning (p<0.05). The opposite relationship, however, was seen in triplet lambs. For each additional second required for triplet-born lambs to follow their dam, lambs were 0.996 (95% CI 0.993 to 0.999) times as likely to survive to weaning (p<0.05). During the maternal recognition test, twin-born lambs were 0.989 (95% CI 0.979 to 1.000) times as likely to survive to weaning for every additional second they took to reach the contact zone (p<0.05). Similarly, triplet-born lambs were 0.994 (95% CI 0.989 to 0.999) as likely to survive for every additional second they took to reach their dam (p<0.05).

Conclusion

All ewe behaviours and the majority of lamb paddock and test behaviours were not associated with the survival of twin- or triplet-born lambs and, therefore, are of little use as indicators of lamb survival to weaning.

Response to First Cycle Is the Major Predictor of Long-Term Response to Lenalidomide and Dexamethasone Therapy in Relapsed and Refractory Multiple Myeloma: Can We Spare Patients the Toxicity and Costs of Additional Agents?

BACKGROUND

Lenalidomide plus dexamethasone (Ld) is still considered an option of care for some selected patients with relapsed or refractory multiple myeloma (RRMM), despite the proven superiority of lenalidomide-based triplet therapy. Up to 20% of patients obtain long-term benefit from Ld alone. The aim of this multicenter retrospective study was to identify and characterize those with good response to Ld salvage therapy, defined as progression-free survival lasting more than 24 months.

PATIENTS AND METHODS

Patients treated with Ld in a consortium of 3 tertiary-care hospitals (Institut Català d'Oncologia) between 2009 and 2016 were prospectively registered; 227 patients had evaluable data.

RESULTS

In multivariate analysis, obtaining partial response after the first therapy cycle was the main independent factor associated with progression-free survival lasting more than 24 months. Together with standard risk cytogenetics, partial response after first cycle was also independently associated with a higher rate of complete response. Previous plasma-cell dyscrasia remained as the only baseline characteristic independently associated with long-lasting responses. High-risk cytogenetics and no history of monoclonal gammopathy of undetermined significance were the only statistically significant negative prognostic factors for overall survival. Patients who had received only one prior therapy showed a trend toward higher overall survival.

CONCLUSION

If Ld is to be considered a treatment choice, at least a partial response should be obtained after the first therapy cycle to maintain double-agent therapy safely.

Continuous Fluorescence Depletion Anisotropy Measurement of Protein Rotation

Protein rotation in viscous environments can be measured by fluorescence depletion anisotropy (FDA) which combines long lifetimes of chromophore triplet states with the sensitivity of fluorescence excitation and detection. FDA achieves sensitivity well beyond that attainable by the more common technique of time-resolved phosphorescence anisotropy (TPA). We have now combined benefits of both time-domain and frequency-domain FDA into a single continuous technique (CFDA). Intensity and polarization of a single laser beam are modulated continuously according to a complex, repeating waveform. Fluorescence signals excited from triplet-forming fluorescent probes are digitized over recurring waveform periods by a high-speed signal averager. CFDA experiments typically involve substantial ground state depletion. Thus signals, unlike those of TPA, are not linear in the exciting light intensity and simple data analysis based on such linearity is not appropriate. An exact solution of the coupled diffusion and triplet production/decay equation describing CFDA within individual data points has been combined with simulated annealing optimization to extract triplet and anisotropy decay kinetics from experimental data. Related calculations compare possible excitation waveforms with respect to rotational information provided per fluorescence photon. We present CFDA results for the model system of eosin conjugates of carbonic anhydrase, BSA and immunoglobulin G in 90% glycerol at various temperatures and initial cellular results on eosin-IgE bound to 2H3 cell Type I Fcε receptors. We explore how CFDA reflects rotational parameters of heterogeneous systems and discuss challenges of extending this method to single cell microscopic measurements.

ATXN2 trinucleotide repeat length correlates with risk of ALS

We investigated a CAG trinucleotide repeat expansion in the ATXN2 gene in amyotrophic lateral sclerosis (ALS). Two new case-control studies, a British dataset of 1474 ALS cases and 567 controls, and a Dutch dataset of 1328 ALS cases and 691 controls were analyzed. In addition, to increase power, we systematically searched PubMed for case-control studies published after 1 August 2010 that investigated the association between ATXN2 intermediate repeats and ALS. We conducted a meta-analysis of the new and existing studies for the relative risks of ATXN2 intermediate repeat alleles of between 24 and 34 CAG trinucleotide repeats and ALS. There was an overall increased risk of ALS for those carrying intermediate sized trinucleotide repeat alleles (odds ratio 3.06 [95% confidence interval 2.37-3.94]; p = 6 × 10-18), with an exponential relationship between repeat length and ALS risk for alleles of 29-32 repeats (R2 = 0.91, p = 0.0002). No relationship was seen for repeat length and age of onset or survival. In contrast to trinucleotide repeat diseases, intermediate ATXN2 trinucleotide repeat expansion in ALS does not predict age of onset but does predict disease risk.

Bacteriopheophytin triplet state in Rhodobacter sphaeroides reaction centers

It is well established that photoexcitation of Rhodobacter sphaeroides reaction centers (RC) with reduced quinone acceptors results in the formation of a triplet state localized on the primary electron donor P with a significant yield. The energy of this long-lived and therefore potentially damaging excited state is then efficiently quenched by energy transfer to the RC spheroidenone carotenoid, with its subsequent decay to the ground state by intersystem crossing. In this contribution, we present a detailed transient absorption study of triplet states in a set of mutated RCs characterized by different efficiencies of triplet formation that correlate with lifetimes of the initial charge-separated state P(+)H A (-) . On a microsecond time scale, two types of triplet state were detected: in addition to the well-known spheroidenone triplet state with a lifetime of ~4 μs, in some RCs we discovered a bacteriopheophytin triplet state with a lifetime of ~40 μs. As expected, the yield of the carotenoid triplet increased approximately linearly with the lifetime of P(+)H A (-) , reaching the value of 42 % for one of the mutants. However, surprisingly, the yield of the bacteriopheophytin triplet was the highest in RCs with the shortest P(+)H A (-) lifetime and the smallest yield of carotenoid triplet. For these the estimated yield of bacteriopheophytin triplet was comparable with the yield of the carotenoid triplet, reaching a value of ~7 %. Possible mechanisms of formation of the bacteriopheophytin triplet state are discussed.

Prediction of perinatal mortality in triplet pregnancies

PURPOSE

To investigate predictors of perinatal mortality in triplet pregnancies.

METHODS

Retrospective cohort managed in a tertiary teaching hospital (1998-2012) including all pregnancies with tree live fetuses at the first ultrasound examination, performed after 11 weeks of gestation. Primary end-point was defined as the number of children alive at hospital discharge. Ordinal stepwise regression analysis examined the association with maternal age, parity, pregnancy chorionicity, gestational age at our first ultrasound evaluation, presence of maternal clinical, obstetrical and fetal complications and gestational age at delivery.

RESULTS

Sixty-seven triplet pregnancies were first seen at 18.5 ± 6.8 weeks, 33 (49.3 %) were trichorionic, obstetric complications occurred in 34 (50.7 %) and fetal complications were diagnosed in 17 (25.4 %). Perinatal mortality rate was 249 ‰ (95 % CI 189-317) and 138 (73 %) children were discharged alive from hospital (11 pregnancies with no survivors; single and double survival in ten cases each; all children alive in 36). Regression analysis showed that presence of fetal complications (OR 0.10, 95 % CI 0.03-0.36) and gestational age at delivery (OR 1.55, 95 % CI 1.31-1.85) are significant predictors of outcome (p < 0.001).

CONCLUSIONS

Perinatal mortality in non-selected triplet pregnancies is high and is related to the presence of fetal complications and gestational age at delivery.

Hybrid Molecule-Nanocrystal Photon Upconversion Across the Visible and Near-Infrared

The ability to upconvert two low energy photons into one high energy photon has potential applications in solar energy, biological imaging, and data storage. In this Letter, CdSe and PbSe semiconductor nanocrystals are combined with molecular emitters (diphenylanthracene and rubrene) to upconvert photons in both the visible and the near-infrared spectral regions. Absorption of low energy photons by the nanocrystals is followed by energy transfer to the molecular triplet states, which then undergo triplet-triplet annihilation to create high energy singlet states that emit upconverted light. By using conjugated organic ligands on the CdSe nanocrystals to form an energy cascade, the upconversion process could be enhanced by up to 3 orders of magnitude. The use of different combinations of nanocrystals and emitters shows that this platform has great flexibility in the choice of both excitation and emission wavelengths.

Synthesis of novel triplets with a 1,3,5-trioxazatriquinane skeleton and their pharmacologies for opioid receptors

We designed and synthesized novel triplet molecules with 1,3,5-trioxazatriquinane skeletons. One class comprises double-capped triplets with a morphinan skeleton; the other class comprises simple phenol derivatives with phenethylamine moieties. One compound with m-phenolic hydroxyl group, called SYK-146, is a highly selective, potent agonist for the κ receptor, with activity nearly equivalent to that of U-50488H. The o-phenolic isomer of SYK-146, called SYK-524, showed potent but non-selective agonistic activity for the opioid receptors. We also added several simple phenol derivatives to a library of compounds that target opioid receptors, and they showed high hit rates for the receptor. This library might also be expected to show high hit rates for other receptors.