Multi-omics analysis identifies potential microbial and metabolite diagnostic biomarkers of bacterial vaginosis

BACKGROUND

Bacterial vaginosis (BV) is a common clinical manifestation of a perturbed vaginal ecology associated with adverse sexual and reproductive health outcomes if left untreated. The existing diagnostic modalities are either cumbersome or require skilled expertise, warranting alternate tests. Application of machine-learning tools to heterogeneous and high-dimensional multi-omics datasets finds promising potential in data integration and may aid biomarker discovery.

OBJECTIVES

The present study aimed to evaluate the potential of the microbiome and metabolome-derived biomarkers in BV diagnosis. Interpretable machine-learning algorithms were used to evaluate the utility of an integrated-omics-derived classification model.

METHODS

Vaginal samples obtained from reproductive-age group women with (n = 40) and without BV (n = 40) were subjected to 16S rRNA amplicon sequencing and LC-MS-based metabolomics. The vaginal microbiome and metabolome were characterized, and machine-learning analysis was performed to build a classification model using biomarkers with the highest diagnostic accuracy.

RESULTS

Microbiome-based diagnostic model exhibited a ROC-AUC (10-fold CV) of 0.84 ± 0.21 and accuracy of 0.79 ± 0.18, and important features were Aerococcus spp., Mycoplasma hominis, Sneathia spp., Lactobacillus spp., Prevotella spp., Gardnerella spp. and Fannyhessea vaginae. The metabolome-derived model displayed superior performance with a ROC-AUC of 0.97 ± 0.07 and an accuracy of 0.92 ± 0.08. Beta-leucine, methylimidazole acetaldehyde, dimethylethanolamine, L-arginine and beta cortol were among key predictive metabolites for BV. A predictive model combining both microbial and metabolite features exhibited a high ROC-AUC of 0.97 ± 0.07 and accuracy of 0.94 ± 0.08 with diagnostic performance only slightly superior to the metabolite-based model.

CONCLUSION

Application of machine-learning tools to multi-omics datasets aid biomarker discovery with high predictive performance. Metabolome-derived classification models were observed to have superior diagnostic performance in predicting BV than microbiome-based biomarkers.

Clinical and health care utilization variables can predict 90-day hospital re-admission in adults with Crohn's disease for point of care risk evaluation

BACKGROUND

Hospital re-admission for persons with Crohn's disease (CD) is a significant contributor to morbidity and healthcare costs. We derived prediction models of risk of 90-day re-hospitalization among persons with CD that could be applied at hospital discharge to target outpatient interventions mitigating this risk.

METHODS

We performed a retrospective study in persons with CD admitted between 2009 and 2016 for an acute CD-related indication. Demographic, clinical, and health services predictor variables were ascertained through chart review and linkage to administrative health databases. We derived and internally validated a multivariable logistic regression model of 90-day CD-related re-hospitalization. We selected the optimal probability cut-point to maximize Youden's index.

RESULTS

There were 524 CD hospitalizations and 57 (10.9%) CD re-hospitalizations within 90 days of discharge. Our final model included hospitalization within the prior year (adjusted odds ratio [aOR] 3.27, 95% confidence interval [CI] 1.76-6.08), gastroenterologist consultation within the prior year (aOR 0.185, 95% CI 0.0950-0.360), intra-abdominal surgery during index hospitalization (aOR 0.216, 95% CI 0.0500-0.934), and new diagnosis of CD during index hospitalization (aOR 0.327, 95% CI 0.0950-1.13). The model demonstrated good discrimination (optimism-corrected c-statistic value 0.726) and excellent calibration (Hosmer-Lemeshow goodness-of-fit p-value 0.990). The optimal model probability cut point allowed for a sensitivity of 71.9% and specificity of 70.9% for identifying 90-day re-hospitalization, at a false positivity rate of 29.1% and false negativity rate of 28.1%.

CONCLUSIONS

Demographic, clinical, and health services variables can help discriminate persons with CD at risk of early re-hospitalization, which could permit targeted post-discharge intervention.

Equitable inclusion of diverse populations in oncology clinical trials: deterrents and drivers

The burden of cancer exerts a disproportionate impact across different regions and population subsets. Disease-specific attributes, coupled with genetic and socioeconomic factors, significantly influence cancer treatment outcomes. Precision oncology promises the development of safe and effective options for specific ethnic phenotypes and clinicodemographic profiles. Currently, clinical trials are concentrated in resource-rich geographies with younger, healthier, white, educated, and empowered populations. Vulnerable and marginalized people are often deprived of opportunities to participate in clinical trials. Despite consistent endeavors by regulators, industry, and other stakeholders, factors including diversity in trial regulations and patient and provider-related cultural, logistic, and operational barriers limit the inclusiveness of clinical trials. Understanding and addressing these constraints by collaborative actions involving regulatory initiatives, industry, patient advocacy groups, community engagement in a culturally sensitive manner, and designing and promoting decentralized clinical trials are vital to establishing a clinical research ecosystem that promotes equity in the representation of population subgroups.

Synthesis of guar gum maleate under dry conditions: Reaction kinetics and characterization

In the present study, a novel environment friendly dry method for preparation of guar gum maleate (GGM) with varying degrees of substitution (DS; 0.02-1.04) was optimized. GGM with a maximum DS of 1.04 was successfully synthesized using guar gum (GG) and maleic anhydride (MA) in proportion of 1: 1 at 80 °C with 4 h of reaction time. The activation energy for the reaction was determined to be 36.91 ± 3.61 kJ mol-1 with pre-exponential factor of 1392 min-1. Esterification of GG was confirmed by FT-IR and 13C NMR. Analysis using size exclusion chromatography (SEC) indicated a decrease in weight average molecular weight (Mw) of the polymer with an increase in polydispersity index (PDI) due to esterification. In comparison with GG, GGM displayed increased hydrophobicity and reduced thermal stability, as analysed by differential scanning calorimetry (DSC). Rheological studies of GGM revealed that initial apparent viscosity decreased with increasing DS. For the first time, the study offered valuable insights on GGM synthesis under dry solvent-less reaction conditions enabling simpler and scalable synthesis process.

An adaptable, reusable, and light implant for chronic Neuropixels probes

Electrophysiology has proven invaluable to record neural activity, and the development of Neuropixels probes dramatically increased the number of recorded neurons. These probes are often implanted acutely, but acute recordings cannot be performed in freely moving animals and the recorded neurons cannot be tracked across days. To study key behaviors such as navigation, learning, and memory formation, the probes must be implanted chronically. An ideal chronic implant should (1) allow stable recordings of neurons for weeks; (2) allow reuse of the probes after explantation; (3) be light enough for use in mice. Here, we present the "Apollo Implant", an open-source and editable device that meets these criteria and accommodates up to two Neuropixels 1.0 or 2.0 probes. The implant comprises a "payload" module which is attached to the probe and is recoverable, and a "docking" module which is cemented to the skull. The design is adjustable, making it easy to change the distance between probes, the angle of insertion, and the depth of insertion. We tested the implant across eight labs in head-fixed mice, freely moving mice, and freely moving rats. The number of neurons recorded across days was stable, even after repeated implantations of the same probe. The Apollo implant provides an inexpensive, lightweight, and flexible solution for reusable chronic Neuropixels recordings.

Assessment of clinical validity of KPG index for 3D classification of impacted maxillary canines by cone beam computed tomography in patients

OBJECTIVES

The primary objective of this study was to assess the validity of the KPG index in predicting the difficulty of treatment involving impacted maxillary canines. The secondary objective was to assess the reliability and reproducibility of the index.

MATERIALS AND METHODS

A retrospective study was conducted on 96 maxillary impacted canines (MIC) in 60 patients aged 13-35 years. Cone-beam computed tomography (CBCT) scans were used to predict the treatment difficulty of MIC using the KPG index. Patient case files were assessed for the actual difficulty encountered in treating MIC. Cohen's kappa correlation coefficient was used for intra-observer reliability and Kendell's W test was used for inter-observer reliability. Spearman's correlation coefficient test was used to assess the correlation between predicted and actual treatment.

RESULTS

Easy and moderately difficult cases exhibited a moderate correlation between actual and predicted treatment outcomes, whereas difficult cases displayed a weak correlation. The perfect correlation was observed exclusively in extremely difficult cases. The intra-observer reliability for assessing CBCT scans using the KPG guide was found to be 0.88, and the inter-rater reliability was 0.94.

CONCLUSION

The KPG index displayed 87%, 71%, 50% and 100% validity in easy, moderately difficult, difficult, and extremely difficult cases, respectively. This index showed good reliability and reproducibility. However, it is imperative to consider a multitude of other factors, including the patient's age, presence of associated root resorption in adjacent teeth, and duration of treatment, to make an informed decision between surgical exposure and extraction.

TROPHY-U-01, a phase II open-label study of sacituzumab govitecan in patients with metastatic urothelial carcinoma progressing after platinum-based chemotherapy and checkpoint inhibitors: updated safety and efficacy outcomes

BACKGROUND

Sacituzumab govitecan (SG) is a Trop-2-directed antibody-drug conjugate containing cytotoxic SN-38, the active metabolite of irinotecan. SG received accelerated US Food and Drug Administration approval for locally advanced (LA) or metastatic urothelial carcinoma (mUC) previously treated with platinum-based chemotherapy and a checkpoint inhibitor, based on cohort 1 of the TROPHY-U-01 study. Mutations in the uridine diphosphate glucuronosyltransferase 1A1 (UGT1A1) gene are associated with increased adverse events (AEs) with irinotecan-based therapies. Whether UGT1A1 status could impact SG toxicity and efficacy remains unclear.

PATIENTS AND METHODS

TROPHY-U-01 (NCT03547973) is a multicohort, open-label, phase II registrational study. Cohort 1 includes patients with LA or mUC who progressed after platinum- and checkpoint inhibitor-based therapies. SG was administered at 10 mg/kg intravenously on days 1 and 8 of 21-day cycles. The primary endpoint was objective response rate (ORR) per central review; secondary endpoints included progression-free survival, overall survival, and safety. Post hoc safety analyses were exploratory with descriptive statistics. Updated analyses include longer follow-up.

RESULTS

Cohort 1 included 113 patients. At a median follow-up of 10.5 months, ORR was 28% (95% CI 20.2% to 37.6%). Median progression-free survival and overall survival were 5.4 months (95% CI 3.5-6.9 months) and 10.9 months (95% CI 8.9-13.8 months), respectively. Occurrence of grade ≥3 treatment-related AEs and treatment-related discontinuation were consistent with prior reports. UGT1A1 status was wildtype (∗1|∗1) in 40%, heterozygous (∗1|∗28) in 42%, homozygous (∗28|∗28) in 12%, and missing in 6% of patients. In patients with ∗1|∗1, ∗1|∗28, and ∗28|∗28 genotypes, any grade treatment-related AEs occurred in 93%, 94%, and 100% of patients, respectively, and were managed similarly regardless of UGT1A1 status.

CONCLUSIONS

With longer follow-up, the ORR remains high in patients with heavily pretreated LA or mUC. Safety data were consistent with the known SG toxicity profile. AE incidence varied across UGT1A1 subgroups; however, discontinuation rates remained relatively low for all groups.

Ustekinumab as induction and maintenance therapy for ulcerative colitis - national extended follow-up and a review of the literature

INTRODUCTION

Ustekinumab use in ulcerative colitis had shown low adverse event and high persistence rates to 3 years via the UNIFI long-term extension study. Outcomes beyond 3 years have not been previously described. We describe the safety signals of the entire UNIFI Australian population beyond 3 years.

METHODS

This retrospective multicenter observational cohort study recruited from all Australian UNIFI centers. The primary outcome was safety via adverse events. Secondary outcomes included the clinical relapse rate on ustekinumab, and the need to switch from ustekinumab to an alternate agent.

RESULTS

There were 14 patients [11 male, mean age 47 (±14) years], with a median diagnosis of 10.8 (±4.5) years prior to UNIFI enrollment. Median follow-up was 298 weeks (5.7 years) (Interquartile range (IQR): 220-311 weeks). Within the long-term extension, there were three serious adverse events and one minor event. 42.9% (6/14) patients had clinical relapses, of which clinical remission was recaptured in 83.3% (5/6). 85.7% (12/14) persisted on ustekinumab in the long-term, with 7.1% (1/14) electively ceasing ustekinumab and 7.1% (1/14) changed from ustekinumab due to clinical relapse.

CONCLUSION

For moderate-to-severe UC in Australia, ustekinumab maintained efficacy beyond 3 years with a high persistence rate and no new safety signals.

TRIAL REGISTRATION

The trial is registered at ANZCTR (identifier: ACTRN12622001332718).

Enhanced Risk Stratification for Children and Young Adults with B-Cell Acute Lymphoblastic Leukemia: A Children's Oncology Group Report

Current strategies to treat pediatric acute lymphoblastic leukemia rely on risk stratification algorithms using categorical data. We investigated whether using continuous variables assigned different weights would improve risk stratification. We developed and validated a multivariable Cox model for relapse-free survival (RFS) using information from 21199 patients. We constructed risk groups by identifying cutoffs of the COG Prognostic Index (PICOG) that maximized discrimination of the predictive model. Patients with higher PICOG have higher predicted relapse risk. The PICOG reliably discriminates patients with low vs. high relapse risk. For those with moderate relapse risk using current COG risk classification, the PICOG identifies subgroups with varying 5-year RFS. Among current COG standard-risk average patients, PICOG identifies low and intermediate risk groups with 96% and 90% RFS, respectively. Similarly, amongst current COG high-risk patients, PICOG identifies four groups ranging from 96% to 66% RFS, providing additional discrimination for future treatment stratification. When coupled with traditional algorithms, the novel PICOG can more accurately risk stratify patients, identifying groups with better outcomes who may benefit from less intensive therapy, and those who have high relapse risk needing innovative approaches for cure.

Sublingual allergen immunotherapy prevents house dust mite inhalant type 2 immunity through dendritic cell-mediated induction of Foxp3+ regulatory T cells

Sublingual allergen immunotherapy (SLIT) is an emerging treatment option for allergic asthma and a potential disease-modifying strategy for asthma prevention. The key cellular events leading to such long-term tolerance remain to be fully elucidated. We administered prophylactic SLIT in a mouse model of house dust mite (HDM)-driven allergic asthma. HDM extract was sublingually administered over 3 weeks followed by intratracheal sensitization and intranasal challenges with HDM. Prophylactic SLIT prevented allergic airway inflammation and hyperreactivity with a low lab-to-lab variation. The HDM-specific T helper (Th)2 (cluster of differentiation 4 Th) response was shifted by SLIT toward a regulatory and Th17 response in the lung and mediastinal lymph node. By using Derp1-specific cluster of differentiation 4+ T cells (1-DER), we found that SLIT blocked 1-DER T cell recruitment to the mediastinal lymph node and dampened IL-4 secretion following intratracheal HDM sensitization. Sublingually administered Derp1 protein activated 1-DER T cells in the cervical lymph node via chemokine receptor7+ migratory dendritic cells (DC). DCs migrating from the oral submucosa to the cervical lymph node after SLIT-induced Foxp3+ regulatory T cells. When mice were sensitized with HDM, prior prophylactic SLIT increased Derp1 specific regulatory T cells (Tregs) and lowered Th2 recruitment in the lung. By using Foxp3-diphtheria toxin receptor mice, Tregs were found to contribute to the immunoregulatory prophylactic effect of SLIT on type 2 immunity. These findings in a mouse model suggest that DC-mediated functional Treg induction in oral mucosa draining lymph nodes is one of the driving mechanisms behind the disease-modifying effect of prophylactic SLIT.

In silico insights into design of novel VEGFR-2 inhibitors: SMILES-based QSAR modelling, and docking studies on substituted benzo-fused heteronuclear derivatives

Eight QSAR models (M1-M8) were developed from a dataset of 118 benzo-fused heteronuclear derivatives targeting VEGFR-2 by Monte Carlo optimization method of CORALSEA 2023 software. Models were generated with hybrid optimal descriptors using both SMILES and Graphs with zero- and first-order Morgan extended connectivity index from a training set of 103 derivatives. All statistical parameters for model validation were within the prescribed limits, establishing the models to be robust and of excellent quality. Among all models, split-2 of M5 was the best-fit as reflected by   r v a lidation 2 ,   Q v a lidation 2 and MAE . Mechanistic interpretation of this model assisted the identification of structural descriptors as promoters and hinderers for VEGFR-2 inhibition. These descriptors were utilized to design novel VEGFR-2 inhibitors (YS01-YS07) by bringing modifications in compound MS90 in the dataset. Docking of all designed compounds, MS90 and sorafenib with VEGFR-2 binding site revealed favourable binding interactions. Docking score of YS07 was higher than that of MS90 and sorafenib. Molecular dynamics simulation study revealed sustained interactions of YS07 with key amino acids of VEGFR-2 at a run time of 100 ns. This study concludes the development of a best fit QSAR model which can assist the design of new anticancer agents targeting VEGFR-2.

Preclinical murine models for the testing of antimicrobials against Mycobacterium abscessus pulmonary infections: Current practices and recommendations

Mycobacterium abscessus, a rapidly growing nontuberculous mycobacterium, is increasingly recognized as an important pathogen of the human lung, disproportionally affecting people with cystic fibrosis (CF) and other susceptible individuals with non-CF bronchiectasis and compromised immune functions. M. abscessus infections are extremely difficult to treat due to intrinsic resistance to many antibiotics, including most anti-tuberculous drugs. Current standard-of-care chemotherapy is long, includes multiple oral and parenteral repurposed drugs, and is associated with significant toxicity. The development of more effective oral antibiotics to treat M. abscessus infections has thus emerged as a high priority. While murine models have proven instrumental in predicting the efficacy of therapeutic treatments for M. tuberculosis infections, the preclinical evaluation of drugs against M. abscessus infections has proven more challenging due to the difficulty of establishing a progressive, sustained, pulmonary infection with this pathogen in mice. To address this issue, a series of three workshops were hosted in 2023 by the Cystic Fibrosis Foundation (CFF) and the National Institute of Allergy and Infectious Diseases (NIAID) to review the current murine models of M. abscessus infections, discuss current challenges and identify priorities toward establishing validated and globally harmonized preclinical models. This paper summarizes the key points from these workshops. The hope is that the recommendations that emerged from this exercise will facilitate the implementation of informative murine models of therapeutic efficacy testing across laboratories, improve reproducibility from lab-to-lab and accelerate preclinical-to-clinical translation.

Abdominal wall reconstruction (AWR) for post-trauma laparotomy ventral hernia and follow-up assessment of functional quality of life (QOL): experience of a level-1 trauma centre in India

PURPOSE

The aim of this study was to examine the postoperative outcomes and follow-up QOL of patients after AWR at a level-1 trauma centre in India.

METHODS

The study cohort included AWR patients treated between January 2011 and July 2022. The Activities Assessment Scale (AAS) was used to measure QOL, and the Ventral Hernia Recurrence Inventory (VHRI) was used to determine the occurrence of recurrence. In patients suspected of having recurrence, thorough clinical examination and relevant imaging were performed to confirm or rule out recurrence.

RESULTS

Out of 89 patients, 35 patients whose complete perioperative and follow-up data were available were enrolled. The mean age of the patients was 28 (SD, 9) years. The mean defect size was 14. 9 (SD, 7) cm. The mean time from laparotomy to AWR surgery was 21 months. During the postoperative course, 37% of patients developed complications, such as SSI and seroma. The mean follow-up time was 53 (SD, 43) months. Upon comparing procedures involving the mesh placed in the sublay position with procedures involving the mesh placed in other positions, no statistically significant difference in the recurrence rate (one in each group, p = 0.99), surgical complication rate (33% v/s 66%, p = 0.6), or mean AAS QOL score (94.7 v/s 98, p = 0.4) was observed. The specificity of the VHRI for diagnosing recurrence was 79%.

CONCLUSION

Overall, the recurrence rate was low in these patients despite the presence of large hernia defects. Long-term QOL was not affected by the specific procedure used. Timely planning and execution are more important than the specific repair approach for post-trauma laparotomy ventral hernia.

Pemigatinib for metastatic or surgically unresectable urothelial carcinoma with FGF/FGFR genomic alterations: final results from FIGHT-201

BACKGROUND

Fibroblast growth factor receptor 3 (FGFR3) alterations are oncogenic drivers of urothelial carcinoma (UC). Pemigatinib is a selective, oral inhibitor of FGFR1-3 with antitumor activity. We report the efficacy and safety of pemigatinib in the open-label, single-arm, phase II study of previously treated, unresectable or metastatic UC with FGFR3 alterations (FIGHT-201; NCT02872714).

PATIENTS AND METHODS

Patients ≥18 years old with FGFR3 mutations or fusions/rearrangements (cohort A) and other FGF/FGFR alterations (cohort B) were included. Patients received pemigatinib 13.5 mg once daily continuously (CD) or intermittently (ID) until disease progression or unacceptable toxicity. The primary endpoint was centrally confirmed objective response rate (ORR) as per RECIST v1.1 in cohort A-CD. Secondary endpoints included ORR in cohorts A-ID and B, duration of response (DOR), progression-free survival (PFS), overall survival (OS), and safety.

RESULTS

Overall, 260 patients were enrolled and treated (A-CD, n = 101; A-ID, n = 103; B, n = 44; unconfirmed FGF/FGFR status, n = 12). All discontinued treatment, most commonly due to progressive disease (68.5%). ORR [95% confidence interval (CI)] in cohorts A-CD and A-ID was 17.8% (10.9% to 26.7%) and 23.3% (15.5% to 32.7%), respectively. Among patients with the most common FGFR3 mutation (S249C; n = 107), ORR was similar between cohorts (A-CD, 23.9%; A-ID, 24.6%). In cohorts A-CD/A-ID, median (95% CI) DOR was 6.2 (4.1-8.3)/6.2 (4.6-8.0) months, PFS was 4.0 (3.5-4.2)/4.3 (3.9-6.1) months, and OS was 6.8 (5.3-9.1)/8.9 (7.5-15.2) months. Pemigatinib had limited clinical activity among patients in cohort B. Of 36 patients with samples available at progression, 6 patients had 8 acquired FGFR3 secondary resistance mutations (V555M/L, n = 3; V553M, n = 1; N540K/S, n = 2; M528I, n = 2). The most common treatment-emergent adverse events overall were diarrhea (44.6%) and alopecia, stomatitis, and hyperphosphatemia (42.7% each).

CONCLUSIONS

Pemigatinib was generally well tolerated and demonstrated clinical activity in previously treated, unresectable or metastatic UC with FGFR3 mutations or fusions/rearrangements.

Deciphering Intermediate Nugent scores: Utility of Real-time PCR for Bacterial Vaginosis diagnosis

PURPOSE

To optimize real-time PCR assays for diagnosis of Bacterial Vaginosis (BV) and determine cut-off loads by ROC analysis for Gardnerella vaginalis, Atopobium vaginae and Lactobacillus spp. as compared to Nugent scoring (Gold standard) in clinical samples.

RESULTS

Out of 125 women, 34 were positive, 26 intermediate and 65 negative for BV by Nugent scoring. All three real-time PCR assays were found to be highly sensitive & specific and AUC suggested excellent diagnostic accuracy. An optimal cut-off was >9.45 × 103 copies/ ml, >3.34 × 103 copies/ ml & ≤ 18.63 × 103 copies/ ml for G. vaginalis, A. vaginae and Lactobacillus spp. respectively, in BV positives. Gram staining and qPCR were discordant only in patients with intermediate scores (n = 26) where qPCR identified 15 (57.69%) as positive and 11 (42.3%) as negative.

CONCLUSION

PCR-based molecular BV diagnosis is more accurate and can be used for deciphering intermediate Nugent scores.

Obstetric anaesthesiology: manpower and service provision issues in India

Obstetric anaesthesiologists play a pivotal role as peripartum physicians steering the team of obstetric healthcare providers towards a continuum of medical education, enhanced training and safer patient care. However, in resource-limited countries, deficiency of human resources and hence services available poses challenges to those attempting to reduce maternal mortality rates. Measures to fill the gap include creating a cadre of uniformly well-trained and certified non-physician anaesthesia providers (NPAPs) supervised by a physician obstetric anaesthesiologist and well-equipped rural and urban health care facilities. The Association of Obstetric Anaesthesiologists of India needs to upscale their outreach programs with regular knowledge updates and practical skill training to the NPAPs, medical graduates and postgraduate doctors in these regions. A combination of strong local administrative will, legislation for the provision of essential supplies and a global collaborative effort using checklists and protocols may help to stem gaps in the provision of safe maternal care.

The Clinical Impact and Cost-Effectiveness of Surveillance of Incidentally Detected Gastric Intestinal Metaplasia: A Microsimulation Analysis

BACKGROUND & AIMS

Gastric intestinal metaplasia (GIM) is associated with a higher risk of noncardia intestinal gastric adenocarcinoma (GA). The aim of this study was to estimate lifetime benefits, complications, and cost-effectiveness of GIM surveillance using esophagogastroduodenoscopy (EGD).

METHODS

We developed a semi-Markov microsimulation model of patients with incidentally detected GIM, to compare the effectiveness of EGD surveillance with no surveillance at 10-year, 5-year, 3-year, 2-year, and 1-year intervals. We modeled a simulated cohort of 1,000,000 US individuals aged 50 with incidental GIM. Outcome measures were lifetime GA incidence, mortality, number of EGDs, complications, undiscounted life-years gained, and incremental cost-effectiveness ratio with a willingness-to-pay threshold of $100,000/quality-adjusted life-year (QALY).

RESULTS

In the absence of surveillance, the model simulated 32.0 lifetime GA cases and 23.0 lifetime GA deaths per 1000 individuals with GIM, respectively. Among surveilled individuals, simulated lifetime GA incidence (per 1000) decreased with shorter surveillance intervals (10-year to 1-year, 11.2-6.1) as did GA mortality (7.4-3.6). Compared with no surveillance, all modeled surveillance intervals yielded greater life expectancy (87-190 undiscounted life-years gained per 1000); 5-year surveillance provided the greatest number of life-years gained per EGD performed and was the cost-effective strategy ($40,706/QALY). In individuals with risk factors of family history of GA or anatomically extensive, incomplete-type GIM intensified 3-year surveillance was cost-effective (incremental cost-effectiveness ratio $28,156/QALY and $87,020/QALY, respectively).

CONCLUSIONS

Using microsimulation modeling, surveillance of incidentally detected GIM every 5 years is associated with reduced GA incidence/mortality and is cost-effective from a health care sector perspective. Real-world studies evaluating the impact of GIM surveillance on GA incidence and mortality in the United States are needed.

Identification using Hand Remnants at the Mass Casualty Site: Forensic Perspective

Identification is one of the most important aspects of mass disasters. Stature estimation is an essential parameter for identification and is widely used in forensic anthropology, where DNA facility is limited. A hand is most studied part of the upper limb; however, data are scarce concerning particular geographical populations. This study is an effort to provide tangible data for such forensic investigations. It was a prospective, cross-sectional study on 500 medicolegal death cases brought for post-mortem examination. It aimed to estimate stature in the Northwest population using hand and finger measurements of dead persons by mathematical models. A total of seven parameters in hand were used to generate linear and multiple regression equations, correlation coefficients and finger indexes for stature estimation and sex differentiation. The correlation coefficient between stature and all the hand measurements were significant except for the index and middle finger on both sides in females. Bilateral differences were insignificant for hand length and breath, except for the middle finger length in both sexes and length of thumb in females. Multiple regression equations for stature estimation were better than linear regression equations for stature estimation. SEE ranged from 4.31 to 6.26 in males and 4.11 to 5.25 in females. For identification, hand length is the best individual parameter among other hand measurements. The measurement accuracy and practical aspects can be enhanced if we consider cadaveric participants. The multiple regression model approach can give a fair estimate of the stature of the deceased.

Dental professional's perspective regarding knowledge, awareness, and attitude towards the importance of charting dental anomalies: a cross-sectional study

OBJECTIVES

The presence of dental anomalies could play a significant role in the identification of individuals by comparing antemortem and postmortem data. This cross-sectional study aimed to assess the level of knowledge, attitude, and awareness among dental professionals regarding the importance of charting dental anomalies and maintaining dental records.

METHODOLOGY

A self-structured questionnaire was e-mailed to dental professionals practicing in India. The responses were recorded, data tabulated, and one-way ANOVA and post hoc tests were applied for analysis. The criterion for significance was p < .05.

RESULTS

A total of 406 dental professionals responded to the survey. A significant difference was observed in the mean attitude score of participants towards the importance of charting dental anomalies and maintaining dental records with regard to place of work (p=.001), gender (p=.044) and educational qualification (p=.039). In addition, a statistically significant difference was observed in the mean awareness score of participants with respect to place of work (p=.033) and gender (p=.001). The major barriers in maintaining dental records were lack of time, adequate knowledge, infrastructure, and financial constraints.

CONCLUSION

81.3% and 69.26% study participants had very good awareness and attitude, whereas 71.2% had good knowledge regarding the importance of charting dental anomalies and maintenance of dental records; however, their inaccurate responses in anomaly identification hinted towards the need for proper dental charting and their maintenance to be taught en masse and made part of the BDS curriculum.

Avelumab first-line maintenance treatment for advanced urothelial carcinoma: review of evidence to guide clinical practice

The JAVELIN Bladder 100 phase III trial led to the incorporation of avelumab first-line (1L) maintenance treatment into international guidelines as a standard of care for patients with advanced urothelial carcinoma (UC) without progression after 1L platinum-based chemotherapy. JAVELIN Bladder 100 showed that avelumab 1L maintenance significantly prolonged overall survival (OS) and progression-free survival in this population compared with a 'watch-and-wait' approach. The aim of this manuscript is to review clinical studies of avelumab 1L maintenance in patients with advanced UC, including long-term efficacy and safety data from JAVELIN Bladder 100, subgroup analyses in clinically relevant subpopulations, and 'real-world' data obtained outside of clinical trials, providing a comprehensive resource to support patient management. Extended follow-up from JAVELIN Bladder 100 has shown that avelumab provides a long-term efficacy benefit, with a median OS of 23.8 months measured from start of maintenance treatment, and 29.7 months measured from start of 1L chemotherapy. Longer OS was observed across subgroups, including patients who received 1L cisplatin + gemcitabine, patients who received four or six cycles of 1L chemotherapy, and patients with complete response, partial response, or stable disease as best response to 1L induction chemotherapy. No new safety signals were seen in patients who received ≥1 year of avelumab treatment, and toxicity was similar in those who had received cisplatin or carboplatin with gemcitabine. Other clinical datasets, including noninterventional studies conducted in Europe, USA, and Asia, have confirmed the efficacy of avelumab 1L maintenance. Potential subsequent treatment options after avelumab maintenance include antibody-drug conjugates (enfortumab vedotin or sacituzumab govitecan), erdafitinib in biomarker-selected patients, platinum rechallenge in suitable patients, nonplatinum chemotherapy, and clinical trial participation; however, evidence to determine optimal treatment sequences is needed. Ongoing trials of avelumab-based combination regimens as maintenance treatment have the potential to evolve the treatment landscape for patients with advanced UC.

Fungi and bacteria in the beds of rural and urban infants correlate with later risk of atopic diseases

INTRODUCTION

Rural children have a lower risk of asthma and atopic diseases than urban children. However, whether indoor microbiota in non-farming rural homes provides protection is unclear.

METHODS

Here, we examine if microbes in the beds of rural and urban infants are associated with later development of atopic diseases. We studied fungi and bacteria in the beds of 6-month-old infants (n = 514) in association with the risk of asthma, allergic rhinitis, eczema and aeroallergen sensitization at 6 years of age in the prospective COPSAC2010 cohort.

RESULTS

Both fungal and bacterial diversity were lower in the beds of children, who later developed allergic rhinitis (-0.22 [-0.43,-0.01], padj  = .04 and -.24 [-0.42,-0.05], padj  = .01 respectively) and lower bacterial richness was discovered in beds of children later developing asthma (-41.34 [-76.95,-5.73], padj  = .02) or allergic rhinitis (-45.65 [-81.19,-10.10], padj  = .01). Interestingly, higher fungal diversity and richness were discovered in the beds of children developing eczema (0.23 [0.02,0.43], padj  = .03 and 29.21 [1.59,56.83], padj  = .04 respectively). We defined a limited set of fungal and bacterial genera that predicted rural/urban environment. Some rural-associated bacterial genera such as Romboutsia and Bacillus and fungal genera Spegazzinia and Physcia were also associated with reduced risk of diseases, including eczema. These fungal and bacterial fingerprints predicting the living environment were associated with asthma and allergic rhinitis, but not eczema, with rural compositions being protective. The bed dust bacteria mediated 27% of the protective association of a rural living environment for allergic rhinitis (p = .04).

CONCLUSIONS

Bed dust microbes can be differentially associated with airway- and skin-related diseases. The differing bed dust microbiota between rural and urban infants may influence their later risk of asthma and allergic rhinitis.

Allergenicity evaluation of quinoa proteins - A study in Brown Norway rats

The popularity of quinoa seeds has increased in the last decade due to their high nutritional value and natural gluten-free composition. Consumption of new proteins may pose a risk of introducing new allergies. In the present study the immunogenicity and sensitising capacity of quinoa proteins were assessed in a dose-response experiment in Brown Norway rats in comparison to proteins from spinach and peanut. Cross-reactivity between quinoa proteins and known allergens was evaluated by in silico analyses followed by analyses with 11 selected protein extracts and their anti-sera by means of ELISAs and immunoblotting. Further, an in vitro simulated gastro-duodenal digestion was performed. Quinoa proteins were found to have an inherent medium to high immunogenicity and sensitising capacity, being able to induce specific IgG1 and IgE levels higher than spinach but lower than peanut and elicit reactions of clinical relevance similar to peanut. Quinoa proteins were generally shown to resist digestion and retain capacity to bind quinoa-specific antibodies. Quinoa proteins were shown to be cross-reactive with peanut and tree nut allergens as high sequence homology and antibody cross-binding were demonstrated. Present study suggests that quinoa pose a medium to high level of allergenicity that should be further investigated in human studies.

Gender differences in workplace violence against physicians and nurses in Latin America: a survey from the Interamerican Society of Cardiology

OBJECTIVES

To evaluate gender differences in workplace violence (WPV) against physicians and nurses in Latin America.

STUDY DESIGN

Cross-sectional study.

METHODS

A cross-sectional electronic survey was conducted between January 11 and February 28, 2022. A prespecified gender analysis was performed.

RESULTS

Among the 3056 responses to the electronic survey, 57% were women, 81.6% were physicians, and 18.4% were nurses. At least one act of violence was experienced by 59.2% of respondents, with verbal violence being the most common (97.5%). Women experienced more WPV than men (65.8% vs 50.4%; P < 0.001; odds ratio [OR]: 1.89; 95% confidence interval [CI]: 1.63-2.19). Women were more likely to report at least one episode of WPV per week (19.2% vs 11.9%, P < 0.001), to request for psychological help (14.5% vs 9%, P = 0.001) and to experience more psychosomatic symptoms. In addition, women were more likely to report having considered changing their job after an aggression (57.6% vs 51.3%, P = 0.011) and even leaving their job (33% vs 25.7%, P = 0.001). In a multivariate analysis, being a woman (OR: 1.76), working in emergency departments (OR: 1.99), and with COVID-19 patients (OR: 3.3) were independently associated with more aggressive interactions, while older age (OR: 0.95) and working in a private setting (OR: 0.62) implied lower risk.

CONCLUSIONS

Women are more likely to experience WPV and to report more psychosomatic symptoms after the event. Preventive measures are urgently needed, with a special focus on high-risk groups such as women.

Insights into microRNA-mediated interaction and regulation of metabolites in tomato

microRNAs direct regulation of various metabolic pathways in plants and animals. miRNAs may be useful in developing novel/elite genotypes, with enhanced metabolites and disease resistance. We examined miRNAs in tomato. In tomato, miRNAs in the carotenoid pathway have not been fully elucidated. We examined the potential role of miRNAs in biosynthesis of carotenoids, transcript profiling of miRNAs and their possible targets (genes and transcription factors) at different development stages of tomato using stem-loop PCR and RT-qPCR. We also identified miRNAs targeting key flavonoid genes, such as chalcone isomerase (CHI), and dihydroflavonol-4-reductase (DFR). Distinct expression profiles of miRNAs and their targets were found in fruits of three tomato accessions, suggesting carotenoid regulation by miRNAs at various stages of fruit development. This was also confirmed using HPLC of the carotenoids. The present study may help in understanding possible regulation of carotenoid biosynthesis. The identified miRNAs can be exploited to enhance biosynthesis of different carotenoids in plants.

T cells specific to multiple Bet v 1 peptides are highly cross-reactive toward the corresponding peptides from the homologous group of tree pollens

Background

Allergens from Fagales trees frequently cause spring allergy in Europe, North America, and some parts of Asia. The definition of the birch homologous group, which includes birch (Bet v), oak (Que a), alder (Aln g), hazel (Cor a), hornbeam (Car b), beech (Fag s), and chestnut (Cas s), is based on high allergen sequence identity and extensive IgE cross-reactivity. Clinical effect was seen during the alder/hazel, birch, and oak pollen seasons after treatment with tree SLIT-tablets containing only birch allergen extract. Here, we characterize T-cell reactivity with respect to epitope specificities and cross-reactivity toward various Bet v 1 family members, (PR-10/group 1 major allergens). This cross-reactivity may be part of the immunological basis of clinical effect or cross-protection when exposed to birch homologous tree species.

Method

T-cell lines were generated from 29 birch-allergic individuals through stimulation of peripheral blood mononuclear cells (PBMCs) with birch/Bet v or oak/Que a allergen extracts. T-cell responses to allergen extracts, purified group 1 allergens, and overlapping 20-mer peptides (Bet v 1, Aln g 1, Cor a 1, and Que a 1) were investigated by T-cell proliferation and cytokine production. Cross-reactivity was evaluated based on Pearson's correlations of response strength and further investigated by flow cytometry using tetramer staining for homologous peptide pairs.

Results

T-cell reactivity toward extracts and group 1 allergens from across the birch homologous group was observed for birch/Bet v as well as oak/Que a T-cell lines. T-cell lines responded to multiple Bet v 1 homologous peptides from Aln g 1 and Cor a 1 and a subset of Que a 1 peptides. Significant Pearson's correlations between frequently recognized peptides derived from Bet v 1 and the corresponding peptides derived from alder, hazel, and oak strongly supported the T-cell cross-reactivity toward these allergens. Cross-reactivity between birch and birch homologous peptides was confirmed by pMHCII tetramer staining.

Conclusion

T cells from birch tree pollen allergic individuals respond to multiple trees within the birch homologous group in accordance with the level of sequence homology between Bet v 1 family members, (PR-10 allergens) from these allergen sources, confirming the basis for clinical cross-protection.

Mid term outcomes of a novel metaphyseal porous titanium cone in revision total knee arthroplasty

Introduction

Bone loss is present in all revision total knee arthroplasties. Metaphyseal cones allow surgeons to negotiate loss of femoral and tibial bone stock while obtaining stable bony fixation. This study examines the mid-term functional and radiographic outcomes in patients undergoing revision total knee arthroplasty (rTKA) utilizing a novel metaphyseal cone system.

Methods

This multicenter retrospective study examined all patients who received a porous, titanium tibial or femoral cone at four academic urban tertiary care institutions and presented for a minimum two-year follow-up. Patient demographics, indications for revision surgery, knee range-of-motion (ROM), re-revision rates, radiographic measurements, bone defect per AORI classification, and implant osseointegration were evaluated according to the Knee Society total knee arthroplasty (TKA) radiographic evaluation system.

Results

One-hundred and four patients received 128 cone implants (84 tibial, 44 femoral cones; 24 patients with simultaneous ipsilateral tibial and femoral cones; 104 rTKA) with mean follow-up of 32.75 ± 6.54 months. The pre-operative main revision indications were aseptic loosening 36 (34.61 %), periprosthetic infection (PJI) 23 (22.11 %) and instability 18 (17.3 %). Thirteen rTKA underwent re-revision surgery: 3 for acute PJI, 4 for chronic PJI, 5 for instability, and 1 for mechanical failure of a hinged system. At most recent radiographic follow-up available, all unrevised cones had evidence of osteointegration and no visible implant migration.All-cause re-operation free survivorship was 87.5 % (91/104), and all-cause cone implant survivorship was 96.09 % (123/128 cones) at 2-year follow-up.

Conclusion

This study demonstrates excellent mid-term outcomes of a novel porous, titanium metaphyseal cone in patients with large bone defects undergoing complex revision TKA.

Level of evidence

IV, case series.

Peri-operative tobacco cessation interventions: a systematic review and meta-analysis

Tobacco smoking is associated with a substantially increased risk of postoperative complications. The peri-operative period offers a unique opportunity to support patients to stop tobacco smoking, avoid complications and improve long-term health. This systematic review provides an up-to-date summary of the evidence for tobacco cessation interventions in surgical patients. We conducted a systematic search of randomised controlled trials of tobacco cessation interventions in the peri-operative period. Quantitative synthesis of the abstinence outcomes data was by random-effects meta-analysis. The primary outcome of the meta-analysis was abstinence at the time of surgery, and the secondary outcome was abstinence at 12 months. Thirty-eight studies are included in the review (7310 randomised participants) and 26 studies are included in the meta-analysis (5969 randomised participants). Studies were pooled for subgroup analysis in two ways: by the timing of intervention delivery within the peri-operative period and by the intensity of the intervention protocol. We judged the quality of evidence as moderate, reflecting the degree of heterogeneity and the high risk of bias. Overall, peri-operative tobacco cessation interventions increased successful abstinence both at the time of surgery, risk ratio (95%CI) 1.48 (1.20-1.83), number needed to treat 7; and 12 months after surgery, risk ratio (95%CI) 1.62 (1.29-2.03), number needed to treat 9. More work is needed to inform the design and optimal delivery of interventions that are acceptable to patients and that can be incorporated into contemporary elective and urgent surgical pathways. Future trials should use standardised outcome measures.

Prospective Characterization of Circulating Tumor Cells in Hormone Sensitive Oligometastatic Prostate Cancer Patients on a Metastasis-Directed Therapy Trial

PURPOSE/OBJECTIVE(S)

Prospective data have shown that metastasis-directed therapy (MDT) can alter the natural history of oligometastatic disease. In hormone-sensitive prostate cancer (HSPC), the clinical effect of MDT has been validated by STOMP, ORIOLE and SABR-COMET phase II trials. Circulating tumor cells (CTCs) are likely the source for the formation of macroscopic metastases. CTCs may provide an approach for identifying subgroups of patients with oligometastatic HSPC (oligoHSPC) that would benefit most from MDT. Our main goal was to evaluate the feasibility of CTC detection and subtypes in oligoHSPC patients that may benefit from MDT.

MATERIALS/METHODS

ORIOLE randomized men with recurrent HSPC with 1-3 metastases to observation (Obs) vs. stereotactic ablative radiotherapy (SABR) MDT. Blood samples were prospectively collected at baseline (D0) and 6-mos (D180) and shipped for analysis on Epic Sciences liquid biopsy platform (Epic Sciences, San Diego, CA). Machine learning algorithms identified CTCs and characterized androgen receptor (AR) and PSMA expression. Association with clinical factors and outcomes were examined. Biochemical failure-free survival (BFFS) event was a PSA rise of at least 2 ng/mL and 25% above nadir. Progression-free survival (PFS) was a composite endpoint including BFFS event, radiologic progression (RECIST v1.1); symptomatic progression; initiation of ADT; or death. Comparisons of patient and tumor characteristics performed by two-sample t-tests. Survival curves were generated by the Kaplan-Meier method and evaluated by the log-rank test. Effect of SABR on post-SABR on CTC levels were calculated by McNemar test.

RESULTS

A total of 82 samples were collected in ORIOLE: 70 SABR (35 D0 and 35 D180) and 12 Obs (7 D0 and 5 D180). 30/42 men had CTCs detected on D0 (71%; AR+ = 7, PSMA+ = 13) and in 26/40 on D180 (65%; AR+ = 9, PSMA+ = 8). Median follow-up was 41.7-mos. There was no association between CTC presence or subtypes (AR+ or PSMA+) with Gleason score or PSA. PFS was significantly lower in the patients with AR+ vs. AR- CTCs on D0 in the SABR arm (p = 0.011, median PFS: AR+ = 9.3- vs. AR+ = 27.1-mos). The median BFFS trended towards a difference for AR+ = 12.9- vs. AR- = 29.2-mos (D180, p = 0.058). SABR had no effect on the presence or subtypes of CTC at D180.

CONCLUSION

Baseline and dynamic CTC levels and their subtypes in oligoHSPC from the ORIOLE randomized trial of MDT was examined. AR+ CTCs at baseline and 6-mos were correlated with clinical outcomes following SABR. Longer follow-up, further analysis and a greater number of patients are needed for a more comprehensive conclusion.

Hippocampal Avoidance Whole BRAIN Radiotherapy (HA-WBRT) with Simultaneous Integrated BOOST (SIB) vs. HA-WBRT in Multiple Brain Metastases: A Dosimetric Comparison

PURPOSE/OBJECTIVE(S)

There has been a paradigm shift in managing multiple brain metastases. Various options include SRS, WBRT, and WBRT with Hippocampal avoidance (HA-WBRT). There is no consensus for the treatment of multiple brain metastases (>3 brain metastases). A new technique that has proven feasible is dose escalation in the form of simultaneous integrated boost. The aim of this study was to compare the dosimetry parameters of HA-WBRT plus simultaneous integrated boost versus HA-WBRT alone in multiple brain metastases.

MATERIALS/METHODS

In a prospective trial,16 patients with multiple brain metastasis (≥ 3) from various primaries with good performance scores (ECOG PS ≤ 2) are recruited. All patients underwent CT simulation (1.5 mm slice thickness) and RT plans for HA-WBRT with (SIB) and HA-WBRT alone were made. A 5 mm margin was given to the bilateral hippocampus for Hippocampal Avoidance. In the HA-WBRT plan for the PTV i.e., whole brain plus 3 mm margin minus hippocampal avoidance region (H.A.), a dose of 30 Gy in 10 fractions is prescribed over two weeks. In HA-WBRT with SIB, a dose of 30 Gy in 10 fractions over two weeks is prescribed for the PTV, which is the clinical target volume, minus the hippocampal avoidance region (H.A.) minus the PTV Mets (1 mm margin to the GTV). A simultaneous Integrated Boost of 42.5 Gy in 10 # over two weeks is prescribed for PTVmets. Planning was done using a VMAT technique with 6MV F.F.F. beam energy in a treatment planning software.

RESULTS

The mean B/L hippocampus volume is 3.47 cc. The mean dose of PTV D98% in HA-WBRT plans is 27.45 Gy, whereas in HA-WBRT with S.I.B. is 27.36 Gy (p = 0.90). V30 mean dose in HA-WBRT plans is 93.35%, and the mean dose in HA-WBRT SIB is 91.87% (p = 0.12). PTV D2% mean dose in HA-WBRT Is 36.06 Gy, and in HA-WBRT -S.I.B., it is 40.58 (p< 0.001). The mean bilateral hippocampus Dmax in HA-WBRT is 14.85 Gy, and in HA-WBRT-SIB is 14.25 Gy (p = 0.35). The mean Bilateral hippocampus D100% is 9.14 Gy in HA-WBRT and 9.01 Gy in HA-WBRT-SIB (p = 0.54). The mean brainstem Dmax in HA-WBRT is 36.82 Gy compared to 38.55 Gy in HA-WBRT-SIB (p = 0.02).

CONCLUSION

In patients planned for a simultaneous boost along with hippocampal sparing whole brain radiotherapy, the mean dose to the hippocampal region did not increase. The Dmax of Brainstem, optic chiasma is significantly higher in HA-WBRT-). Our study, the mean dose to PTVmets is more than 45 Gy and more than 50 Gy to GTV with a BED of more than 65 Gy (α/ß = 10) to the metastases, which is equivalent to some ablative dose regimens. Simultaneous integrated boost along with hippocampal sparing radiotherapy thus helps in sparing the hippocampus and delivering higher doses to the metastases and intermediate doses to the rest of the brain, addressing the microscopic disease.

Identification and molecular characterization of two recurrent missense mutations in the RS1 gene in two families with X-linked retinoschisis from North India

X-linked retinoschisis (XLR) is a rare medical condition that involves in the splitting of neurosensory layers and the impairment of vision in the retina. In majority of the XLR cases, pathogenic variants in Retinoschisin 1 (RS1) gene have been implicated in males with an early age of onset during early childhood. In the present study, we have recruited two North Indian families having multiple affected male members, who were diagnosed with XLR. The entire protein-coding region of RS1 was screened by PCR-Sanger sequencing and two recurrent pathogenic variants (p.I81N and p.R102Q) were unraveled. The in vitro study of these variants demonstrated the aggregation of mutant RS1 within the endoplasmic reticulum. Furthermore, mutant forms of this protein showed significant intracellular retention, which was evident by the absence of retinoschisin protein fractions in the extracellular media. These inferences were also supported by extensive bioinformatics analysis of the mutants, which showed dramatic conformational changes in the local structure of retinoschisin. Thus, our study suggests that the identified pathogenic variants interfere with proper protein folding, leading to anomalous structural changes ultimately resulting in intracellular retention of retinoschisin within the retina.

Role of Stereotactic Body Radiation Therapy in Portal Vein Tumor Thrombosis in Hepatocellular Carcinoma: A Prospective Single Institute Experience

PURPOSE/OBJECTIVE(S)

Patients diagnosed with Hepatocellular carcinoma (HCC) complicated with portal vein tumor thrombosis (PVTT) have a limited number of treatment options available and are associated with an overall poor prognosis. With the recent developments in the field of radiation therapy, the role of radiotherapy particularly Stereotactic Body radiotherapy (SBRT) has increased as a loco-regional therapy for HCC. This study was planned to evaluate the role of SBRT in Locally advanced HCC complicated with PVTT and its role as loco-regional therapy.

MATERIALS/METHODS

We conducted a prospective study that included patients diagnosed with HCC complicated with PVTT Child-Turcotte Pugh (CTP) Class A/B with a maximum score of 7, diagnosed on triple phase Contrast-Enhanced - MRI unsuitable for other ablative procedures. Patients with Bilirubin levels > 4 mg/dl, active Hepatitis, CTP score >7, normal liver volume <700cc or history of prior radiotherapy were excluded from the study. Patients underwent a contrast enhanced 4D-CT simulation with abdominal compression and were planned for SBRT using VMAT technique. Patients were followed-up as per Institute protocol. CECT or MRI for a radiological response was done for response assessment using mRECIST criteria version 1.1. A baseline MRI was done at one-month post-SBRT to understand any RT changes in the liver and to differentiate from tumor progression during the response assessment at three months.

RESULTS

A total of 22 patients with HCC were recruited and received SBRT to PVTT, with a dosage between 30-42 Gy over 6 fractions treated on alternate days. Patients were assessed post-treatment with triphasic CE-MRI every 3 months as per institute protocol. Five patients had achieved Complete response in form of Portal vein recanalization. Three patients had Partial response to the treatment. Seven patients maintained stable disease status whereas six patients had disease progression during the entire course of treatment. The response rate (CR+PR) to treatment was 36.3% at the time of analysis. The Overall Response rate (CR+PR+SD) was 69%. No grade 3 or 4 toxicities were observed and treatment was tolerated well by patients. Kaplan-Meier method was applied to calculate the survival probability at various follow-up intervals. The median time for overall survival was 25 months ((95% CI: 15-35). Out of the 22 subjects included in the study, 6 patients died. There was a 78% survival probability at 12 months and a 68% survival probability at 18 months of follow-up.

CONCLUSION

This prospective single-arm study demonstrated the vital role of SBRT in the treatment of Hepatocellular carcinoma with Portal vein tumor thrombosis and its efficacy in terms of achieving excellent local control with relatively lesser toxicities compared with existing treatment modalities. Patients have shown benefit post-treatment in terms of thrombus reduction and restoration of Portal vein flow making them suitable for further treatment like Resection or TACE.

Multiple Sessions vs. Single Session Image-Based Intracavitary Brachytherapy for Locally Advanced Cervical Cancer: A Randomized Control Trial

PURPOSE/OBJECTIVE(S)

The objectives of this study are: 1) To compare the acute toxicity caused in the treatment of locally advanced cervical cancer (LACC) treated with weekly multiple applications vs. a single application for image-guided intracavitary High Dose Rate (HDR) brachytherapy (BT) after External Beam Radiation Therapy (EBRT) 2) To compare the loco-regional control of cancer at six months in the two arms MATERIALS/METHODS: In a prospective study, 40 patients with biopsy-proven LACC with FIGO-2018 stage IIB-IIIC1 disease, underwent EBRT to the pelvis at a dose of 50.4 Gy/ 28 fractions over 5.5 weeks with weekly concurrent cisplatin. After completion of EBRT, they were randomized into two arms with 20 patients each. In the Control arm (Arm-A), BT sessions were given with weekly 3 applications whereas, in the experimental arm (Arm-B), all the sessions were given with a single application at 6-12 hours intervals with aim of the high-risk clinical target volume receiving >80 Gy EQD2 and 2 cm3 of the bladder and rectum/sigmoid receiving <85 Gy and <75 Gy, respectively. The OAR contouring was done on CT RESULTS: All 40 patients were treated as per protocol. The mean duration of treatment including EBRT and BT was 73.15 days [95% CI 68.63-77.66] in Arm A and 55.85 days [95% CI 52.11-59.58] in Arm B which was significant. After 6 months, 37 patients came for follow-up, all 19 patients in Arm A had Grade 1 or Grade 2 rectal toxicity. In Arm B as well all 18 patients had Grade 1 or Grade 2 rectal toxicity. Bladder toxicity was Grade 1 or Grade 2 in 18 patients and Grade 3 severity in 1 patient among Arm A. Among 18 patients of Arm B, bladder toxicity of Grade 1 or Grade 2 was seen in 16 patients, and 2 patients had grade 3 toxicity. 2 patients in Arm A and 3 in Arm B complained of Grade 1 urinary incontinence. Moreover, Abdominal pain at 6 months was of Grade 1 in around 6 patients in Arm A but 14 patients had abdominal pain in Arm B which was of Grade 1 in 8, 4 had grade 2 and 2 patients had grade 3 severity abdominal pain. In the monthly analysis of acute toxicity, none of the patients showed Grade 3 or 4 toxicity at the 1st, 2nd, or 3rd month of completion of treatment. When comparing local control in both arms at 6 months, 2 patients had treatment failure in the Experimental Arm compared to only 1 patient in the Control Arm CONCLUSION: Single Application Multiple Fraction Intracavitary Brachytherapy post concurrent CTRT is a safe option for the treatment of locally advanced cervical cancer. When compared to the weekly application arm, single-application ICRT showed a comparable acute toxicity profile and comparable local control rates as well. Some patients in Single Application Arm showed abdominal pain which needs to be investigated with further trials. The overall treatment time in the single application arm is significantly lower than the standard weekly application arm.

Biological Response Assessment in Hepatocellular Carcinoma Post Stereotactic Body Radiotherapy

PURPOSE/OBJECTIVE(S)

Biological Response in Hepatocellular carcinoma (HCC) is measured in terms of serum alpha-fetoprotein (AFP) which is elevated in nearly 60% HCC patients at baseline and is directly related to the severity of the disease. This biological response is defined as the reduction of more than 50% from the baseline levels and is associated with an increased percentage of tumor necrosis and is directly related to increased loco-regional control. Patients diagnosed with HCC have very limited treatment modalities. With the recent advances in the field of radiation therapy and the development of Stereotactic Body radiotherapy (SBRT), the role of radiotherapy has increased as a loco-regional modality for HCC. In this single-arm prospective study, we evaluated the biological response post-SBRT in patients diagnosed with HCC.

MATERIALS/METHODS

We conducted a prospective study that included patients diagnosed with HCC with baseline elevation of serum AFP, Child-Turcotte Pugh (CTP) Class A/B with a maximum score of 7. Patient's serum AFP levels were recorded at baseline, pre-treatment, and post-treatment. The biological response was measured at 3 months post-treatment and compared with the baseline serum AFP levels using Wilcoxon signed rank test.

RESULTS

A total of 14 patients with HCC were recruited and received SBRT to the target lesion, with a dose between 30-42 Gy over 6 fractions treated on alternate days. Patients were assessed post-treatment at one month with triphasic CEMRI and serum AFP levels. 12 out of 14 patients (85.71%) had a biological response at 3 months follow-up and levels showed further decline unless a progression was found. The median (IQR) serum AFP level was 1131 ng/ml (359-5668 ng/ml) at baseline. Post-treatment serum AFP levels had a median (IQR) value of 156 ng/ml (15-372 ng/ml) showing a near reduction of 86% from baseline, which was significant. 2/14 pts (14.28%) showed no reduction or even increase in serum AFP levels post-treatment.

CONCLUSION

This prospective single-arm study demonstrated the vital role of SBRT in the treatment of HCC and its importance in achieving a better disease control. The response was achieved in 86% of patients with marked reduction of nearly 90% in serum AFP levels as compared to the baseline and increased median OS and PFS as compared to patients not receiving radiotherapy. Further prospective studies are warranted to confirm our findings.

Trial in Progress: Adaptive RADiation Therapy with Concurrent Sacituzumab Govitecan (SG) for Bladder Preservation in Patients with MIBC (RAD-SG)

PURPOSE/OBJECTIVE(S)

A substantial proportion of patients with muscle invasive bladder cancer do not receive curative intent therapy, especially if unfit for or refuse radical cystectomy. Concurrent chemoradiation is an effective alternative to radical cystectomy, however systemic radio-sensitizing chemotherapy may have off target side effects. A Phase I study is accruing which will investigate the concurrent administration of a bladder cancer targeted antibody drug conjugate (Sacituzumab Govitecan) with radiotherapy.

MATERIALS/METHODS

This trial in progress is a Phase I study of Adaptive RADiation therapy with concurrent Sacituzumab Govitecan (SG) for bladder preservation in patients with muscle invasive bladder cancer (MIBC). Eligible patients will have localized muscle invasive bladder cancer (MIBC) confined to the bladder. The initial cohort is expected to accrue 20 patients. The primary endpoint is to establish the safety, tolerability, and feasibility of bladder preservation therapy treatment with concurrent SG and adaptive image-guided radiation therapy for patients with localized MIBC. The secondary endpoints are to determine the bladder intact event-free survival (BI-EFS) with concurrent SG and radiation therapy for MIBC and compare to historical controls with other concurrent chemoradiation regimens. BI-EFS is defined as the time from treatment to the first documented occurrence of residual/recurrent MIBC, nodal or distant metastases on imaging, radical cystectomy, or death from any cause. Sacituzumab Govitecan targets TROP-2, a surface protein expressed in urothelial cancers of the bladder. SG will be delivered IV, 10 mg/kg, 21-day cycles for 1 loading cycle prior to radiation and two subsequent cycles with concurrent adaptive radiotherapy over a period of 6 weeks (64 Gy). Correlative objectives (Supported by NCI/NIH U54) and will involve 1) elucidation of the genetic and microenvironmental mechanisms that drive efficacy and resistance to combined ADC plus radiation therapy and 2) characterization of tumor clonal dynamics, immune repertoire editing, and imaging changes following treatment with SG plus radiation.

RESULTS

To be determined.

CONCLUSION

To be determined.

Knowledge, awareness and attitude of dental professionals regarding child maltreatment

BACKGROUND

Dental professionals could play a significant role in identifying, documenting and reporting child maltreatment to appropriate authorities as children are exposed to various maltreatments that can present in the head and neck region.

AIM

The aim of this paper is to assess the level of knowledge, awareness and attitude among dental professionals regarding child maltreatment and to identify the barriers that prevent reporting suspected maltreatment.

METHODOLOGY

The present cross-sectional questionnaire-based study was conducted on dental professionals practising in India by emailing a self-structured questionnaire to assess knowledge, awareness and attitude regarding child maltreatment.

RESULTS

422 dental professionals participated in the survey of which 270 were females. A significant difference was observed in mean knowledge (p=.015), awareness (p=.014) score of the participants with regard to place of work and mean knowledge score (p=.024) of the participants with regard to educational qualification. 300 participants reported that lack of adequate knowledge and awareness about the role of dental professionals regarding child maltreatment is one of the major barriers that prevent reporting child maltreatment.

CONCLUSION

Findings of the study showed that 43.8% of participants had good knowledge and 44.8% were fairly aware regarding child maltreatment. 86.7% of participants showed a very good attitude towards learning more about the role of dental professionals in the management of child maltreatment.

Thin film epitaxial [111] Co[Formula: see text]Pt[Formula: see text]: structure, magnetisation, and spin polarisation

Ferromagnetic films with perpendicular magnetic anisotropy are of interest in spintronics and superconducting spintronics. Perpendicular magnetic anisotropy can be achieved in thin ferromagnetic multilayer structures, when the anisotropy is driven by carefully engineered interfaces. Devices with multiple interfaces are disadvantageous for our application in superconducting spintronics, where the current perpendicular to plane is affected by the interfaces. Robust intrinsic PMA can be achieved in certain Co[Formula: see text]Pt[Formula: see text] alloys and compounds at any thickness, without increasing the number of interfaces. Here, we grow equiatomic Co[Formula: see text]Pt[Formula: see text] and report a comprehensive study on the structural, magnetic, and spin-polarisation properties in the [Formula: see text] and [Formula: see text] ordered compounds. Primarily, interest in Co[Formula: see text]Pt[Formula: see text] has been in the [Formula: see text] crystal structure, where layers of Pt and Co are stacked alternately in the [100] direction. There has been less work on [Formula: see text] crystal structure, where the stacking is in the [111] direction. For the latter [Formula: see text] crystal structure, we find magnetic anisotropy perpendicular to the film plane. For the former [Formula: see text] crystal structure, the magnetic anisotropy is perpendicular to the [100] plane, which is neither in-plane or out-of-plane in our samples. We obtain a value for the ballistic spin polarisation of the [Formula: see text] and [Formula: see text] Co[Formula: see text]Pt[Formula: see text] to be [Formula: see text].

Outcome of a Simple Novel Technique to Reduce Soft Tissue Complications in Open Tendoachilles Injury: A Series of 20 Patients

Introduction

Open tendoachilles injuries are rare and associated with significant soft tissues complications. The objective of the present study was to assess the clinical outcome and safety of a simple and minimally invasive technique, with a goal to assess if it may help minimise flap and wound related complications in open tendoachilles injuries.

Materials and methods

This prospective study of four years duration included 20 patients with open tendoachilles injuries managed with a simple minimally invasive tunnel technique. The primary outcome variable was occurrence of a major soft tissue complication. The secondary outcome variables included functional outcome measured using AOFAS Ankle hind foot score, re-rupture of tendoachilles and need for revision surgery.

Results

None of the patients in the present series developed a serious soft tissue complication. Based upon the AOFAS hind foot scoring system, good to excellent outcome was achieved in 19 (95%) patients. All the patients were able to perform tip toe walking at six months post-surgery. None of the patients had a re-rupture of the tendoachilles and no patient needed a revision surgery. The complications encountered include thickening of the tendon at the repair site (15%), superficial wound infection (5%), stitch granuloma (5%) and hypertrophic scar (5%).

Conclusion

This technique seems to be promising in reducing the soft tissue complications associated with the surgical management of open tendoachilles injuries. Most patients had a good final clinical outcome. The technique is safe, simple and reproducible. However, further randomised control studies with a larger sample size assessing the technique are recommended.

THE IMPACT OF CLIMATE CHANGE ON INFECTIOUS DISEASES: A COMPREHENSIVE ANALYSIS OF VECTOR-BORNE DISEASES, WATER-BORNE DISEASES, AND PUBLIC HEALTH STRATEGIES

Climate change is long-term modifications to weather patterns and a rise in extreme weather events. It might modify the hazard to human health and exacerbate current problems. The article explores the scientific data in a description of the effects of Infectious diseases in humans and climate change. It identifies scientific advancements and gaps in potential responses from human civilization and how it might prepare for the changes that come with it by adjusting to them. The impact reflects three aspects, such as climate variables, selected infectious diseases, and infectious disease components. This study demonstrates how vulnerable people are to any ill consequences that climate change may have on their health. Humans can actively influence controllable correlated health impacts by taking proactive measures, such as increasing our understanding of the detrimental effects associated with specific diseases and the patterns in climate change. We can also carefully distribute technology and resources, encouraging exercise and public awareness. It is advised to take the following adaption measures: Considering how infectious diseases and climate change are not the only things that science has discovered and create locally efficient early warning systems for those effects to produce more scientific justifications and go beyond scientific reports. Improve prediction of the spatiotemporal processes behind climate change and changes in infectious illnesses connected at different temporal and spatial scales.

AMR Sign - An Arthroscopic S-shaped Fold Signifying Adequate Medial Meniscus Repair

Introduction

The preferred management of medial meniscus tears has notably moved from meniscectomies towards repair. With a higher volume of meniscal repairs being done all across the world with every passing day, the lack of an objective and definitive sign suggesting the adequacy of its repair is daunting. The purpose of our study was to introduce a unique and novel arthroscopic sign formed after adequate repair of the medial meniscus, the AMR (Adequacy of Medial meniscus Repair) sign. We hypothesised that it is not only the objective end point for repair, but can also form the indicator for excellent clinical, functional, and radiological outcome even in the long term.

Materials and methods

This was a multicentric, prospective study initiated by the corresponding author, and the findings validated subsequently by the other authors. Overall, it included 804 patients of isolated medial meniscus tear operated with arthroscopic all-inside technique between January 2014 and December 2017. Patients were segregated into three groups based on whether an S-shaped curve in the free, inner edge of the medial meniscus sign was formed post-repair, lost after further tightening, or not formed upon subjective completion of repair. All the patients were followed-up and evaluated based of medial joint line tenderness, McMurray's test for medial meniscus, IKDC score, WOMET score, and radiologically using an MRI at the terminal follow-up.

Results

The mean terminal follow-up was 42.34±4.54 months. There was significant (p<0.01) improvement in all patients at the terminal follow-up post-surgery, irrespective of the group. The group in which AMR sign was formed and maintained showed a significantly better functional outcome on terminal follow-up as well as lower failure rates compared to the other two groups.

Conclusion

AMR sign is an S-shaped fold at the inner, free edge of medial meniscus, formed after an adequate repair of isolated medial meniscus tear, as viewed on arthroscopy. It is an objective sign denoting regained integrity of the collagen architecture of the medial meniscus following repair. It is also a reliable indicator of excellent long term functional, clinical, and radiological outcome and also lower failure rates in patients after arthroscopic medial meniscus repair.

Pan-Asian adapted ESMO Clinical Practice Guidelines for the diagnosis, staging and treatment of patients with metastatic breast cancer

The most recent version of the European Society for Medical Oncology (ESMO) Clinical Practice Guidelines for the diagnosis, staging and treatment of patients with metastatic breast cancer (MBC) was published in 2021. A special, hybrid guidelines meeting was convened by ESMO and the Korean Society of Medical Oncology (KSMO) in collaboration with nine other Asian national oncology societies in May 2022 in order to adapt the ESMO 2021 guidelines to take into account the differences associated with the treatment of MBC in Asia. These guidelines represent the consensus opinions reached by a panel of Asian experts in the treatment of patients with MBC representing the oncological societies of China (CSCO), India (ISMPO), Indonesia (ISHMO), Japan (JSMO), Korea (KSMO), Malaysia (MOS), the Philippines (PSMO), Singapore (SSO), Taiwan (TOS) and Thailand (TSCO). The voting was based on the best available scientific evidence and was independent of drug access or practice restrictions in the different Asian countries. The latter were discussed when appropriate. The aim of these guidelines is to provide guidance for the harmonisation of the management of patients with MBC across the different regions of Asia, drawing from data provided by global and Asian trials whilst at the same time integrating the differences in genetics, demographics and scientific evidence, together with restricted access to certain therapeutic strategies.

Novel unconventional radiotherapy techniques: Current status and future perspectives - Report from the 2nd international radiation oncology online seminar

•Improvement of therapeutic ratio by novel unconventional radiotherapy approaches.•Immunomodulation using high-dose spatially fractionated radiotherapy.•Boosting radiation anti-tumor effects by adding an immune-mediated cell killing.

Acyldepsipeptide Antibiotics and a Bioactive Fragment Thereof Differentially Perturb Mycobacterium tuberculosis ClpXP1P2 Activity in Vitro

Proteolytic complexes in Mycobacterium tuberculosis (Mtb), the deadliest bacterial pathogen, are major foci in tuberculosis drug development programs. The Clp proteases, which are essential for Mtb viability, are high-priority targets. These proteases function through the collaboration of ClpP1P2, a barrel-shaped heteromeric peptidase, with associated ATP-dependent chaperones like ClpX and ClpC1 that recognize and unfold specific substrates in an ATP-dependent fashion. The critical interaction of the peptidase and its unfoldase partners is blocked by the competitive binding of acyldepsipeptide antibiotics (ADEPs) to the interfaces of the ClpP2 subunits. The resulting inhibition of Clp protease activity is lethal to Mtb. Here, we report the surprising discovery that a fragment of the ADEPs retains anti-Mtb activity yet stimulates rather than inhibits the ClpXP1P2-catalyzed degradation of proteins. Our data further suggest that the fragment stabilizes the ClpXP1P2 complex and binds ClpP1P2 in a fashion distinct from that of the intact ADEPs. A structure-activity relationship study of the bioactive fragment defines the pharmacophore and points the way toward the development of new drug leads for the treatment of tuberculosis.

The Comparative Accuracy of BISAP and PANC3 Scoring System for the Disease Severity and Outcome in Acute Pancreatitis in Tertiary Care Hospital from North India

Background Acute pancreatitis has local and systemic manifestations, so it's important to assess the severity by various scoring system. Among them bed side index for severity of acute pancreatitis and pancreatitis three score have been considered to be more predictive and easier. Objective To determine the comparative prognostic value of bed side index for severity of acute pancreatitis and pancreatitis 3 score and its correlation with the outcome. Method A prospective observational study was conducted on 50 cases of acute pancreatitis. The patients were assessed clinically, radiologically and biochemically and were categorised into mild, moderate and severe category as per Atlanta Classification. Bed side index for severity of acute pancreatitis and pancreatitis 3 score was calculated at the time of admission and followed till the time of discharge or they had mortality. Result Receiver operating characteristic curve, showed bed side Index for severity of acute pancreatitis score had sensitivity (66.67%), specificity (84.09%), diagnostic accuracy (84%) while pancreatitis 3 score had sensitivity (50%), specificity (81.82%), diagnostic accuracy (80%) for the severity of acute pancreatitis. Bed side index for severity of acute pancreatitis had sensitivity (100%), specificity (66.67%) and Pancreatitis 3 score had sensitivity (66.67%), specificity (80.85%) for predicting the mortality in acute pancreatitis. Conclusion Bed side index for severity of acute pancreatitis and pancreatitis 3 score are both simple, bedside tool for assessing the severity and mortality but bed side index for severity of acute pancreatitis score had better sensitivity, specificity for assessing the severity and mortality as compared to pancreatitis three score.

Secular equilibrium assessment in a CaWO4 target crystal from the dark matter experiment CRESST using Bayesian likelihood normalisation

CRESST is a leading direct detection sub-GeVc^-2 dark matter experiment. During its second phase, cryogenic bolometers were used to detect nuclear recoils off the CaWO₄ target crystal nuclei. The previously established electromagnetic background model relies on Secular Equilibrium (SE) assumptions. In this work, a validation of SE is attempted by comparing two likelihood-based normalisation results using a recently developed spectral template normalisation method based on Bayesian likelihood. Albeit we find deviations from SE in some cases we conclude that these deviations are artefacts of the fit and that the assumptions of SE is physically meaningful.

The value of cardiopulmonary exercise testing and stress echocardiography in the prediction of all-cause mortality in adults with end-stage renal disease

We aimed to assess the prognostic utility of different parameters routinely assessed from cardiopulmonary exercise testing (CPET) and exercise echocardiography in adults with end-stage renal disease (ESRD). Forty-two ESRD (37 male) individuals (age: 58 ± 13 years, height: 169.30 ± 8.30 cm, weight: 81 ± 15 kg, body surface area: 1.92 ± 0.20 m²) underwent a maximal/symptom limited CPET, with a full cross-sectional echocardiogram performed at baseline and peak exercise. All participants were prospectively followed over a 10-year period, with all-cause mortality as the primary endpoint. After the follow-up period, a total of 19 participants (45%) died. Left atrial size (4.70 ± 0.70 vs. 3.65 ± 0.50 cm, P < 0.001) and anteroseptal wall thickness (1.28 ± 0.40 vs. 1.06 ± 0.02 cm, P = 0.002) were significantly greater in those that died, while peak heart rate was significantly lower (108 ± 12 vs. 128 ± 14 bpm, P < 0.001). The prevalence of myocardial ischaemia (13 vs. 8 participants, P = 0.03) was significantly greater, while peak VO₂ (9.80 ± 2.10 vs. 15.90 ± 4.30 ml·kg^-1·min^-1, P < 0.001) was significantly lower in those that died. Following multivariate cox regression, myocardial ischaemia (Hazard Ratio 3.08; 95% Confidence Interval 1.09-8.70; P = 0.03) and peak VO₂ (HR 0.73; 95% CI 0.64-0.84; P < 0.001) were significant independent predictors of 10-year all-cause mortality. This is the first study to establish peak VO₂ as powerful marker of all-cause mortality when assessed with clinical, resting and stress echocardiography parameters in people with ESRD over a 10-year follow up period. This observation indicates that, in clinical practice, CPET and exercise echocardiography may serve as valuable tools for the risk stratification of individuals with ESRD. HIGHLIGHTSWe aimed to assess the prognostic utility of cardiopulmonary exercise testing (CPET) and exercise echocardiography in end-stage renal disease (ESRD) with 10-year mortality.Peak aerobic capacity and the presence of ischaemic heart disease were independently associated with all-cause mortality.This observation indicates that, in clinical practice, CPET and exercise echocardiography may serve as valuable tools for the risk stratification of individuals with end-stage renal disease.