Mutational Characteristics and Clinical Outcomes for Lung Adenocarcinoma With EGFR Germline Mutations.

INTRODUCTION: Germline mutations driving lung cancer have been infrequently reported in the literature, with EGFR T790M being a known germline mutation identified in 1% of NSCLCs. Typically, a somatic EGFR mutation is acquired to develop lung adenocarcinoma. Osimertinib has become a standard-of-care treatment for EGFR T790M-positive lung cancer. METHODS: We perform a retrospective analysis through the Lung Cancer Moon Shot GEMINI database at the University of Texas MD Anderson Cancer Center. Of the patients that underwent cell-free DNA analysis, germline mutations were identified by those with high variant allelic fraction approximating 50%, followed by further confirmation on genetic testing. RESULTS: We identified 22 patients with germline EGFR mutations, with the majority harboring an EGFR T790M mutation (95.5%) and an EGFR L858R somatic mutation (50%). Notably, most patients were female (86.4%), non-smokers (81.8%), white (86.4%), had a family history of lung cancer (59.1%), and stage IV at diagnosis (72.7%). A distinct radiographic pattern of small multifocal ground-glass pulmonary nodules was observed in the majority of our cohort (72.7%). Among the 18 with advanced-stage NSCLC, 12 patients (66.7%) were treated with first-line osimertinib, demonstrating a median progression-free survival (PFS) of 16.9 months (95% confidence interval [CI]: 6.3-not reached [NR]). Others were treated with first-line afatinib (11.1%) or chemotherapy (22.2%). Among the 17 patients treated with osimertinib (in first or second-line), median PFS was 20.4 months (95% CI: 6.3-NR) and median overall survival was 82.0 months (95% CI: 28.4-NR). CONCLUSIONS: Based on our institutional cohort, NSCLC driven by EGFR germline mutations occurs more frequently in non-smoking, white females with multi-focal pulmonary nodules radiographically. Osimertinib for advanced germline EGFR-mutated NSCLC renders similar PFS compared to somatic T790M EGFR-mutated NSCLC.

A different approach to teaching pre-clerkship students physical diagnosis: standardized patient instructor-senior medical student teaching teams.

BACKGROUND: Faculty have traditionally taught the physical examination (PE) to novice medical students (pre-clerkship students.), despite recruiting and cost issues and problems standardizing their approach. ACTIVITY: We present a model using standardized patient instructor (SPI)-fourth year medical student (MS4) teams to teach PE to pre-clerkship students, leveraging the benefits of co-teaching and peer-assisted learning. RESULTS: Surveys of pre-clerkship students, MS4s and SPIs indicate positive perceptions of the program, including MS4s reporting significant growth in their professional identities as educators. Pre-clerkship students' performance on the spring clinical skills exams was equivalent to or better than their peer performance pre-program implementation. IMPLICATIONS: SPI-MS4 teams can effectively teach novice students the mechanics and clinical context of the beginners' physical exam.

Understanding of Factors Associated with Reporting to the Police, Helping Seeking, and Adopting in Self-protection among Stalking Victims: A Latent Class Analysis.

Victims of stalking use multiple help-seeking behaviors including reporting their experiences to the police, obtaining a restraining order, blocking communication, and relying on informal social networks like friends, family, or therapists. The goal of this study is to, first, identify distinct subgroups of stalking victims based on their help-seeking behaviors. Next, we identify the direct effect of sex, victim-offender relationship, and offense severity on class membership. Finally, we include negative emotions as a mediating effect. Using the 2016 National Crime Victimization Survey's Supplemental Victimization Survey data, latent class analysis was utilized to identify class membership among 1,459 stalking victims. The results indicate three groups: passive help-seekers, informal help-seekers, and active help-seekers. We found that females are more likely to be assigned to the active or informal group and these two groups appear to experience more severe stalking behaviors compared to the passive group. Specifically, victims were less likely to ask for help actively and ask family, friends, and non-professional people for help for whom stalking took place by other/unable to identify individuals. Victims whose stalkers had a criminal record, whose stalkers threatened themselves or others, as well as who suffered stalking lasting for months and the most often were more likely to ask for help actively and ask family, friends, and non-professional people for help. The significance of victims' perceptions of severity of both groups is only partially mediated by negative emotions.

Las víctimas del acoso utilizan diversos comportamientos de búsqueda de ayuda, como denunciar los hechos a la policía, conseguir una orden de alejamiento, bloquear la comunicación o confiar en las redes sociales informales como amigos, familia o terapeutas. El objetivo del estudio es en primer lugar reconocer distintos subgrupos de víctimas de acoso en función de sus comportamientos de búsqueda de ayuda. A continuación observamos el efecto directo en la pertenencia al grupo del sexo, la relación víctima-agresor y la gravedad del delito. Por último, abordamos el efecto mediador de las emociones negativas. Utilizando los datos de la encuesta suplementaria de victimización de la Encuesta Nacional de Delitos de Victimización de 2016 nos servimos del análisis de clases latentes para analizar la afiliación de clase en 1,459 víctimas de acoso. Los resultados muestran tres grupos: buscadores de ayuda pasivos, informales y activos. Resultó que es más probable que las mujeres sean asignadas al grupo activo o informal y que estos dos grupos parecen experimentar comportamientos de acoso más graves en comparación con el grupo pasivo. En concreto era menos probable que las víctimas pidieran ayuda activamente y a la familia, amigos y personas no profesionales que habían sufrido acoso por parte de otras personas incapaces de identificar. Era más probable que las víctimas cuyos acosadores tenían antecedentes penales y les habían acosado a ellos o a otras personas y cuyo acoso había durado meses y más a menudo pidieran ayuda activa y también a la familia, amigos y personas no profesionales. La importancia de cómo percibían la gravedad ambos grupos solo estaba mediatizada en parte por las emociones negativas.

Effects of 3-nitrooxypropanol manure fertilizer on soil health and hydraulic properties.

Supplementing beef cattle with 3-nitrooxypropanol (3-NOP) decreases enteric methane production, but it is unknown if fertilizing soil with 3-NOP manure influences soil health. We measured soil health indicators 2 yr after manure application to a bromegrass (Bromus L.) and alfalfa (Medicago sativa L.) mixed crop. Treatments were: composted conventional manure (without supplements); stockpiled conventional manure; composted manure from cattle supplemented with 3-NOP; stockpiled 3-NOP manure; composted manure from cattle supplemented with 3-NOP and monensin (3-NOP+Mon), a supplement that improves digestion; stockpiled 3-NOP+Mon manure; inorganic fertilizer (150 kg N ha-1 and 50 kg P ha-1 ); and an unamended control. Select chemical (K+ , Mg2+ , Mn+ , Zn+ , pH, and Olsen-P), biological (soil organic matter, active C, respiration, and extractable protein), physical (wet aggregate stability, bulk density, total porosity, and macro-, meso-, and micro-porosity), and hydraulic (saturation, field capacity, wilting point, water holding capacity, and hydraulic conductivity) variables were measured. The inclusion of monensin decreased soil Zn+ concentrations by 70% in stockpiled 3-NOP+Mon compared with stockpiled conventional manure. Active C and protein in composted conventional manure were 37 and 92% higher compared with stockpiled manure, respectively, but did not vary between 3-NOP treatments. 3-Nitrooxypropanol did not significantly alter other soil health indicators. Our results suggest that composted and stockpiled 3-NOP manure can be used as a nutrient source for forage crops without requiring changes to current manure management because it has minimal influence on soil health.

Exploring Patient-Reported Costs Related to Hepatitis C on the Medical Crowdfunding Page GoFundMe®.

BACKGROUND: Successful medical crowdfunding campaigns may alleviate or even eliminate the financial burden of expensive, cumulative medical bills. GoFundMe® crowdfunding pages for hepatitis C virus (HCV) patients were reviewed and analyzed to better understand the characteristics that contribute to a successful fundraising campaign in a disease often associated with patients with a lower social standing or stigma. METHODS: A pilot cross-sectional study of all publicly available GoFundMe® crowdfunding pages was conducted for posts related to HCV on GoFundMe® in June 2019. Similar to data extraction steps in a systematic literature review, page data were reviewed to identify whether the source of the patient's HCV infection was disclosed, if disclosed then how did the patient report contracting the disease, and all costs reported in the description as part of the rationale for requesting funds. Descriptive statistics of category and numeric variables were reported for the full sample, and exploratory analyses were conducted to determine any potential associations with categorical variables and the amount of donations received, categorized as small (< US$1000), moderate (US$1000-4999), and large (≥ US$5000). RESULTS: A total of 685 unique GoFundMe® pages were included in the analysis. Only 30% (206/685) of the pages disclosed the source of HCV infection. Of those that disclosed a virus source, 86% (177/206) described a source that appeared more socially desirable to our research team (blood transfusion, organ transplant, occupational exposure, etc.). In terms of actual donations received by a page, 46% (312/685) were less than US$1000, 38% (262/685) were between US$1000 and US$4999, and 16% (111/685) were US$5000 or more. Disclosing the virus source was associated with a higher donation category (p = 0.0099). CONCLUSION: These exploratory findings yield important insights, both for patients or caregivers seeking support on GoFundMe® crowdfunding websites and for researchers interested in exploring the types of costs self-reported by patients in their public requests for financial assistance.

Greenhouse gas and ammonia emissions from stored manure from beef cattle supplemented 3-nitrooxypropanol and monensin to reduce enteric methane emissions.

The investigative material 3-nitrooxypropanol (3-NOP) can reduce enteric methane emissions from beef cattle. North American beef cattle are often supplemented the drug monensin to improve feed digestibility. Residual and confounding effects of these additives on manure greenhouse gas (GHG) emissions are unknown. This research tested whether manure carbon and nitrogen, and GHG and ammonia emissions, differed from cattle fed a typical finishing diet and 3-NOP [125-200 mg kg-1 dry matter (DM) feed], or both 3-NOP (125-200 mg kg-1 DM) and monensin (33 mg kg-1 DM) together, compared to a control (no supplements) when manure was stockpiled or composted for 202 days. Consistent with other studies, cumulative GHGs (except nitrous oxide) and ammonia emissions were higher from composted compared to stockpiled manure (all P < 0.01). Dry matter, total carbon and total nitrogen mass balance estimates, and cumulative GHG and ammonia emissions, from stored manure were not affected by 3-NOP or monensin. During the current experiment, supplementing beef cattle with 3-NOP did not significantly affect manure GHG or NH3 emissions during storage under the tested management conditions, suggesting supplementing cattle with 3-NOP does not have residual effects on manure decomposition as estimated using total carbon and nitrogen losses and GHG emissions.

Improved Species-Level Clinical Identification of Enterobacteriaceae through Broad-Range dnaJ PCR and Sequencing.

Enterobacteriaceae represent a diverse and medically important family of bacteria that are difficult to identify to the species level using the standard molecular method of 16S rRNA gene sequencing. Prior work has demonstrated the value of dnaJ gene sequence analysis in resolving different members of the family. However, existing protocols are not optimized for clinical use and exhibit several limitations in practice. Here, we describe an improved assay for dnaJ-based identification of Enterobacteriaceae which boasts increased broad-range specificity across genera, shorter amplicon sizes that are suitable for use with formalin-fixed or direct patient specimens, and enhanced amplification efficiency and assay sensitivity through the incorporation of locked nucleic acid chemistries. Sequence analysis of public databases indicates that the partial dnaJ sequence interrogated by this design retains high discriminatory power among Enterobacteriaceae genera and species, with only particular lineages of Shigella sp. and Escherichia coli proving unresolvable. Limits of detection studies using 8 disparate species indicated that amplification was consistently achievable across organisms and allowed robust dideoxynucleotide chain terminator sequencing from as little as 10 genome equivalents of template, depending on the species interrogated. Retrospective application of the dnaJ assay to patient specimens enabled unambiguous classification of Enterobacteriaceae to the species level in 22 of 27 (81.5%) positive specimens examined, with most remaining cases representing unresolvable calls between closely related Escherichia coli and Shigella species. We expect that this assay will facilitate the accurate molecular identification of species from the Enterobacteriaceae family in a variety of clinical specimens and diagnostic contexts.

Cadmium Uptake by Ryegrass and Ryegrass-Clover Mixtures under Different Liming Rates.

Cadmium accumulates in soils that receive repeated applications of Cd-rich superphosphate fertilizers. There is evidence that adding clovers to a crop solubilizes soil Cd, increasing the bioavailability of Cd. This can lead to high plant Cd concentrations. This research aimed to test whether liming-induced increases in pH in mixed crops of clovers and ryegrasses reduced forage Cd concentrations. A greenhouse pot trial applied lime at three rates (0, 1, and 2% of soil dry weight) to eight different plant treatments-four as monocultures (perennial ryegrass [ L.], Italian ryegrass [ Lam.], white clover [ L.], and red clover [ L.]) and four as ryegrass-clover mixtures (two plant types in each treatment)-in soil (initial soil pH = 5.1, initial soil Cd concentration = 1.31 mg kg) with added Cd (CdSO ∼ 1 mg kg). Adding lime increased soil pH in both mono- and mixed crops and, in most treatments, increased forage yields. However, the relationship between forage Cd and soil pH differed between plant treatments. In mono- and mixed crop treatments containing perennial ryegrass, adding lime increased the forage yield but did not increase the mass of Cd in the plants compared with the no-lime treatment. However, adding lime to treatments that included Italian ryegrass increased both the forage yield and the Cd compared with the no-lime treatment. The results show that a combination of certain plant species composition and lime rates can optimize forage yields without increasing forage Cd concentrations.

Revealing Victimization: The Impact of Methodological Features in the National Crime Victimization Survey.

This study examines the impact of methodological features of the National Crime Victimization Survey (NCVS) on respondent willingness to report violent, serious violent, and property victimizations to the NCVS. Bounded and unbounded data from the 1999-2005 NCVS are used to create a longitudinal file of respondents, and survey-weighted logistic regression models are used to assess the factors associated with the reporting of victimization. Net of sociodemographic control variables, unbounded interviews produced higher estimates of serious violence (72%), violence (66%), and property victimization (67%). Mobile respondents reported higher estimates than nonmobile respondents of serious violence (48%), violence (35%), and property victimization (15%). Compared with in-person interviews, interviewing by telephone increased reporting for serious violence (7%), violence (12%), and property victimization (17%). This study highlights the importance of controlling for these factors in both longitudinal and cross-sectional analyses to estimate victimization risk.

Medicalized addiction, self-medication, or nonmedical prescription drug use? How trust figures into incarcerated women's conceptualization of illicit prescription drug use.

Trust is crucial to optimal care. When trust is compromised, patients, doctors, and others involved in the provision of health care may not act in patients' best interests, particularly when dealing with prescription (Rx) drugs. Patients must trust that doctors are giving them the proper treatment, including access to Rx drugs only when medically necessary. They must also trust themselves to use these drugs properly. Likewise, doctors must trust the patient's ability to use medications appropriately. Given the recent rise in illicit Rx drug use in the U.S., we seek to understand how women articulate levels of trust in doctors and themselves and if different combinations of trust and distrust impact how they acquire, use, and articulate their experiences with Rx drugs. To this end, we identified and interviewed 40 women incarcerated in the U.S., who were deeply entrenched in illicit Rx drug use prior to prison. Based upon this research, we argue that illicit Rx drug use may be tied to different combinations of trust and distrust in individual doctors (interpersonal trust), the field of medicine (institutional trust), and the users themselves (self trust). How these women acquire Rx drugs: through doctors, friends, family, or the street market are influenced by combinations of interpersonal, institutional, and self trust.

Isolation and characterization of hepatic mast cells from cholestatic rats.

Mast cells (MCs) are immune cells that release histamine and other mediators. MC number increases after bile duct ligation (BDL) and blocking mast cell-derived histamine decreases biliary proliferation. We aimed to isolate and characterize MCs from cholestatic livers. Rats were subjected to BDL starting at 6 h and up to 14 days. MC infiltration was evaluated by toluidine blue. BDL rats were perfused using standard collagenase perfusion. Following enzymatic digestion, tissue was passed through a fine gauge needle. Suspensions were incubated with MAb AA4, washed and incubated with goat anti-mouse-coated Dynal beads. MCs were stained with toluidine blue, and in isolated MCs the expression of FCɛRI and MC proteases was measured. The expression of histidine decarboxylase, histamine receptors, VEGF receptors, and TIE 1 and 2 was evaluated by qPCR. Histamine and VEGF-A secretion was measured in MC supernatants. MC purity was evaluated by CK-19, CK-8, albumin, VAP-1, and α-SMA expression. In vitro, cholangiocytes and HSCs were treated with isolated MC supernatants from BDL rats treated with either NaCl or cromolyn sodium (to block MC histamine release) and biliary proliferation and hepatic fibrosis were measured. MCs infiltrate the liver and surround bile ducts starting at day 2. We isolated a virtually pure preparation of mature, functional MCs. TEM images reveal distinct secretory granules and isolated MCs secrete histamine. MCs express FCɛRI, chymase, tryptase, RMCP-I, and RMCP-II, but were virtually void of other cell markers. Biliary proliferation and fibrosis increased following treatment with MC supernatants from BDL rats+NaCl and these parameters decreased in cells treated with MC supernatants from BDL+cromolyn sodium. In conclusion, we have isolated and characterized MCs from cholestatic livers. MCs regulate cholestatic liver injury and hepatic fibrosis. This tool provides a better understanding of the paracrine influence of mast cells on biliary/liver pathologies.

Inhibition of mast cell-secreted histamine decreases biliary proliferation and fibrosis in primary sclerosing cholangitis Mdr2(-/-) mice.

UNLABELLED: Hepatic fibrosis is marked by activation of hepatic stellate cells (HSCs). Cholestatic injury precedes liver fibrosis, and cholangiocytes interact with HSCs promoting fibrosis. Mast cells (MCs) infiltrate following liver injury and release histamine, increasing biliary proliferation. We evaluated if inhibition of MC-derived histamine decreases biliary proliferation and fibrosis. Wild-type and multidrug resistance 2 knockout mice (9-11 weeks) were treated with cromolyn sodium for 1 week to block MC-derived histamine. Biliary mass and proliferation were evaluated by immunohistochemistry for cytokeratin 19 and Ki-67. Bile flow, bicarbonate excretion, and total bile acids were measured in all mice. Fibrosis was evaluated by sirius red/fast green staining and by quantitative polymerase chain reaction for alpha-smooth muscle actin, fibronectin, collagen type 1a, and transforming growth factor-beta 1. HSC activation was evaluated by quantitative polymerase chain reaction in total liver and immunofluorescent staining in tissues for synaptophysin 9. Histamine serum secretion was measured by enzymatic immunoassay. Mouse liver and human liver samples from control or primary sclerosing cholangitis patients were evaluated for MC markers by quantitative polymerase chain reaction and immunohistochemistry. In vitro, cultured MCs were transfected with histidine decarboxylase short hairpin RNA to decrease histamine secretion and subsequently cocultured with cholangiocytes or HSCs prior to measuring fibrosis markers, proliferation, and transforming growth factor-beta 1 secretion. Treatment with cromolyn sodium decreased biliary proliferation, fibrosis, histamine secretion, and bile flow in multidrug resistance 2 knockout mice. Primary sclerosing cholangitis mice and patients have increased MCs. Knockdown of MC histidine decarboxylase decreased cholangiocyte and HSC proliferation/activation. CONCLUSION: MCs are recruited to proliferating cholangiocytes and promote fibrosis. Inhibition of MC-derived histamine decreases fibrosis, and regulation of MC mediators may be therapeutic for primary sclerosing cholangitis. (Hepatology 2016;64:1202-1216).

Interdisciplinary Workshop to Increase Collaboration Between Medical Students and Standardized Patient Instructors in Teaching Physical Diagnosis to Novices.

INTRODUCTION: Traditionally, full-time faculty members have assumed major responsibility for teaching physical examination skills to first- and second-year medical students. Problems with faculty recruitment and adhering to a standardized way of teaching have challenged educators to seek alternatives to teaching the physical examination to novices. To address these problems, we created and implemented a novel curriculum that has standardized the teaching of physical examination skills to novice students by using standardized patient instructors (SPIs) and fourth-year medical students (MS-4s) working as an interdisciplinary team (known as a dyad). METHODS: This dyad training workshop occurs early in the school year, before first-year medical students begin their physical diagnosis course. Prior to the workshop, SPIs and MS-4s receive prereading on which they are quizzed both individually and as a preassigned dyad, during the session. The workshop requires a total of 100 minutes and includes several discussions on formative learning theory, roles, and teamwork. RESULTS: In 2013, 16 SPIs (100%) and 44 MS-4s (77%) completed a 4-question questionnaire. The majority (> 80%) of respondents selected agree or strongly agree for all four questions. DISCUSSION: While initial feedback from SPIs and MS-4s was enthusiastically positive, evidence showed the dyad could be strengthened by (1) providing time to learn the theoretical scaffolding underlying working together, (2) meeting and planning approaches to teaching efforts, and (3) enabling medical students and standardized patient instructors to apply the theoretical constructs as the foundation to reflect on their teaching roles in effectively instructing novices in physical exam skills.

Inhibition of Mast Cell-Derived Histamine Decreases Human Cholangiocarcinoma Growth and Differentiation via c-Kit/Stem Cell Factor-Dependent Signaling.

The tumor microenvironment of cholangiocarcinoma (CCA) is composed of numerous cells, including mast cells (MCs). MCs release histamine, which increases CCA progression and angiogenesis. Cholangiocytes secrete stem cell factor, which functions via the MC growth factor receptor c-Kit. Here, we show that cholangiocytes express histidine decarboxylase and its inhibition reduces CCA growth. MC recruitment in the tumor microenvironment increased CCA growth. MC infiltration and MC markers were detected by toluidine blue staining and real-time PCR in human biopsies and in tumors from athymic mice treated with saline, histamine, histidine decarboxylase inhibitor, or cromolyn sodium. Tumor growth, angiogenesis, and epithelial-mesenchymal transition (EMT)/extracellular matrix (ECM) markers were measured in mice treated with cromolyn sodium. In vitro, human CCA cells were treated with MC supernatant fluids before evaluating angiogenesis and EMT/ECM expression. Migration assays were performed with CCA cells treated with the stem cell factor inhibitor. MC supernatant fluids increased CCA histidine decarboxylase, vascular endothelial growth factor, and MC/EMT/ECM expression that decreased with pretreatment of cromolyn sodium. MCs were found in human biopsies. In mice treated with cromolyn sodium, MC infiltration and tumor growth decreased. Inhibition of CCA stem cell factor blocked MC migration and MC/EMT/ECM in CCA. MCs migrate into CCA tumor microenvironment via c-Kit/stem cell factor and increase tumor progression, angiogenesis, EMT switch, and ECM degradation.

Why Definitions Matter: Stalking Victimization in the United States.

Although there is a growing understanding of stalking victimization, it remains difficult to define, and characterizations of the phenomenon vary within the literature. As such, research is needed to understand how variations in the definition of stalking may change who is defined as a victim and thereby limit the generalizability of findings across previous studies. The focus of this study is the inclusion or exclusion of subjective and reasonable measures of fear for 1,430 victims identified by the 2006 Supplemental Victimization Survey. Results suggest that the definition of stalking is important, and prior research has potentially excluded stalking victims due to restrictive operationalizations. Victims who report different types of fear appear to be similar to each other in some respects but differ in others, particularly with regard for gender representation, suggesting some definitions of stalking may be gendered and under-represent male stalking victims. Finally, using complex stratified survey weights, the impact of these varying operationalizations is examined. Using the same data but different definitions resulted in estimates of just over 1 to 5.3 million persons who are stalked in the United States each year.

Effect of enhanced psychosocial assessment on readmissions of patients with chronic obstructive pulmonary disease.

In 2015, the Patient Protection and Affordable Care Act of 2010 will mandate reduced Medicare reimbursements for hospitals with Chronic Obstructive Pulmonary Disease (COPD) readmissions that are higher than expected. Several studies identified social issues as a concern and possible contributor to readmissions. This study calculated readmission rates for patients with COPD following an enhanced psychosocial assessment. With 26 participants serving as their own historical controls, a paired t-test of the mean of admissions 90 days prior to the assessment and 90 days postassessment was conducted. The study group had a significantly lower number of readmissions in the 90 days postintervention.