Persistent Features of Laryngeal Injury Following Endotracheal Intubation: A Systematic Review.

This systematic review examined (i) prevalence, severity, and impact of persistent post-extubation laryngeal injury beyond hospital discharge and (ii) differences in persistent laryngeal injury between COVID-19 and non-COVID-19 populations. The review was completed following PRISMA-2020 guidelines. Four databases (PubMed, CINHAL complete, EMBASE, Web of Science) were searched (inception to March 2021). Screening, full text review and data extraction were completed by two reviewers. Primary outcomes were swallow, voice and cough and airway measures obtained after hospital discharge. Quality assessment was measured using Downs & Black Tool and Johanna Briggs Institute Checklist for Cohort Studies. Meta-analysis was not completed due to study heterogeneity. Six cohort studies were included. Total number of participants across the included studies was 436. ICU admission diagnoses included respiratory disease 46% (COVID-19 and non-COVID-19), sepsis 14%, non-sepsis-related organ dysfunction 9%, general medical 11%, general surgical 10%, trauma 2%, ENT 0.6% and other not specified by authors 7%. Outcomes were obtained between 2 and 60 months post hospital discharge. Assessment methods included endoscopic evaluation, clinician ratings and patient-reported outcomes. Persistent features of laryngeal injury identified were airway abnormalities (18.9-27%), dysphonia (13.2-60%) and dysphagia (23-33%). Persistent laryngeal injury was associated with ICU length of stay, respiratory diagnosis and tracheostomy. Study quality ranged from poor-good. This is the first systematic review to examine post-extubation laryngeal injury beyond hospital discharge. Significant gaps in the literature were identified. Given the impact on clinical and patient outcomes, large scale, well-designed research is needed to guide post-ICU service delivery.

Systematic review of postradiotherapy bronchiolitis obliterans organizing pneumonia in women with breast cancer.

BACKGROUND: Radiation therapy for breast cancer has been implicated in the development of bronchiolitis obliterans organizing pneumonia (BOOP). This inflammatory lung disorder was first noted in 1983, and there have been numerous reports of BOOP occurring in women who have had radiation therapy for breast cancer since 1995. This study was undertaken to perform a systematic review of postradiotherapy BOOP to determine the occurrence, presentation, treatment, and outcome. MATERIALS AND METHODS: A systematic literature review was conducted according to the guidelines provided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses report. RESULTS: The literature search yielded 10 Japanese epidemiological reports with 129 women, 4 case series reports with 36 women, and 24 case reports with 34 women. Common symptoms included fever, cough, and shortness of breath. Most patients received corticosteroid therapy, and duration of treatment ranged from 6 months to 1 year, although some patients received steroids for longer than 1 year because of relapse, which occurred in approximately one half of patients. No deaths have been reported. CONCLUSION: BOOP is a rare but significant complication from radiation therapy for breast cancer. Chest radiographic studies for women who report new respiratory symptoms during the postradiation period can be beneficial for early diagnosis and for guiding appropriate management.

Assessing the oral and suprahyoid muscles in healthy adults using muscle ultrasound to inform the swallowing process: a proof-of-concept study.

The oral and suprahyoid muscles are responsible for movements of swallowing. Our study aimed to determine the reproducibility of static and dynamic measurements of these muscles using bedside ultrasound equipment. Forty healthy participants were recruited prospectively. Primary outcomes were evaluation of mass measurements of the anterior bellies of the digastric, mylohyoid, geniohyoid and tongue in B-mode ultrasound. Secondary outcomes were evaluation of geniohyoid muscle layer thickness and function using M-mode. Muscle mass measurements demonstrated little within-participant variability. Coefficient of Variance (CoV) across muscles were: anterior belly digastric (5.0%), mylohyoid (8.7%), geniohyoid (5.0%) and tongue (3.2%). A relationship between sex (r2 = 0.131 p = 0.022) was demonstrated for the geniohyoid muscle, with males having higher transverse Cross Sectional Area (CSA) (14.3 ± 3.6 mm vs. 11.9 ± 2.5 mm, p = 0.002). Tongue size was correlated with weight (r2 = 0.356, p = 0.001), height (r2 = 0.156, p = 0.012) and sex (r2 = 0.196, p = 0.004). Resting thickness of the geniohyoid muscle layer changed with increasing bolus sizes (f = 3.898, p = 0.026). Velocity increased with bolus size (p = < 0.001, F = 8.974). However swallow time and slope distance did not, potentially influenced by higher coefficients of variation. Oral and suprahyoid muscle mass are easily assessed using bedside ultrasound. Ultrasound may provide new information about muscle mass and function during swallowing.

Evolution of attenuating mutations in dengue-2 strain S16803 PDK50 vaccine and comparison of growth kinetics with parent virus.

A live-attenuated dengue-2 virus strain S16803 vaccine candidate that is immunogenic and safe in humans was derived by 50 passages in primary dog kidney (PDK) cells. To identify mutations associated with attenuation of the dengue-2 PDK50 vaccine strain, we determined the nucleotide changes that arose during PDK passage of the dengue-2 virus. Thirteen mutations distinguished the PDK50 virus from low-passage parent resulting in amino acid substitutions in the premembrane (E89G), envelope (E202K, N203D), nonstructural proteins NS1 (A43T), NS2A (L181F), NS2B (I26V), and NS4B (I/T108T, L112F). In addition, the PDK50 virus contained a C to T change of nucleotide 57 in the 5' non-coding region and four silent mutations of nucleotides 591, 987, 6471, and 8907. An infectious PDK50 cDNA clone virus was produced and characterized for growth kinetics in monkey (LLC-MK(2), Vero) and mosquito (C6/36) cells. Identification of mutations in the vaccine strain and availability of an infectious clone will permit systematic analysis of the importance of individual or collective mutations on attenuation of dengue virus.

Post-Breast Cancer Radiotherapy Bronchiolitis Obliterans Organizing Pneumonia.

BACKGROUND: Radiotherapy for breast cancer has been implicated in the development of bronchiolitis obliterans organizing pneumonia (BOOP). Patients may be asymptomatic or may have pulmonary and constitutional symptoms that are moderate or severe. Postradiotherapy BOOP usually develops during the 12 months after completion of radiotherapy and is characterized by ground-glass opacities in the radiation-exposed lung and frequently in the non-irradiated lung. METHODS: An updated literature search and review was performed to update the systematic review we conducted in 2014. Ten new publications were identified: 2 Japanese epidemiological studies, 1 Japanese case series study, 6 case reports, and 1 review article. RESULTS: The incidence of postradiotherapy BOOP was 1.4% in both Japanese epidemiological studies. Risk factors included increasing age, cigarette smoking, and increasing central lung distance. The case reports included 7 women who had breast cancer postradiation BOOP and 1 woman who had an ataxia telangiectasia mutated (ATM) gene mutation, which may increase radiation sensitivity. CONCLUSION: Postradiotherapy BOOP in women with breast cancer occurs at a rate of 1.0-3.0% and may occur in women with immune system dysfunction and genetic mutations.

Förster transfer recovery reveals that phospholamban exchanges slowly from pentamers but rapidly from the SERCA regulatory complex.

Phospholamban (PLB) or the sarcoplasmic reticulum Ca2+-ATPase (SERCA) were fused to cyan fluorescent protein (CFP) and coexpressed with PLB fused to yellow fluorescent protein (YFP). The expressed fluorescently tagged proteins were imaged using epifluorescence and total internal reflection fluorescence microscopy. YFP fluorescence was selectively bleached by a focused laser beam. CFP fluorescence at the targeted site increased after YFP photobleaching, indicating fluorescence resonance energy transfer between CFP-SERCA/CFP-PLB and YFP-PLB. The increased donor fluorescence relaxed back toward baseline as a result of donor diffusion and exchange of bleached YFP-PLB for unbleached YFP-PLB, which restored fluorescence resonance energy transfer. Requenching of CFP donors, termed Förster transfer recovery (FTR), was quantified as an index of the rate of PLB subunit exchange from the PLB:SERCA and PLB:PLB membrane complexes. PLB subunit exchange from the PLB:SERCA regulatory complex was rapid, showing diffusion-limited FTR (tau=1.4 second). Conversely, PLB:PLB oligomeric complexes were found to be stable on a much longer time scale. Despite free lateral diffusion in the membrane, they showed no FTR over 80 seconds. Mutation of PLB position 40 from isoleucine to alanine (I40A-PLB) did not abolish PLB:PLB energy transfer, but destabilization of the PLB:PLB complex was apparent from an increased FTR rate (tau=8.4 seconds). Oligomers of I40A-PLB were stabilized by oxidative crosslinking of transmembrane cysteines with diamide. We conclude that PLB exchanges rapidly from its regulatory complex with the SERCA pump, whereas subunit exchange from the PLB oligomeric complex is slow and does not occur on the time scale of the cardiac cycle.

High-Dose Rate Salvage Interstitial Brachytherapy: A Case-Based Guide to the Treatment of Therapeutically Challenging Recurrent Vulvar Cancer.

Vulvar cancer is a rare gynecological malignancy with incidence rates steadily increasing over the past 10 years. Despite aggressive treatment, recurrent disease is common. Vulvar cancer recurrence poses a significant therapeutic challenge as most patients have been previously treated with surgery and/or radiation limiting the options for additional treatment. There are no consensus guidelines for the treatment of recurrent disease. Current literature supports the use of salvage interstitial brachytherapy. However, the total sample size is small. The goal of this case report is to review the current literature and to provide a guide for the use of salvage interstitial brachytherapy for recurrent disease by describing, in detail, the techniques used to treat two patients with unique cases of vulvar cancer recurrences in women with advanced disease and multiple medical comorbidities.

Prior Authorization for Medications in a Breast Oncology Practice: Navigation of a Complex Process.

INTRODUCTION: The cost and burden associated with prior authorization (PA) for specialty medications are concerns for oncologists, but the impact of the PA process on care delivery has not been well described. We examined PA processes and approval patterns within a high-volume breast oncology clinic at a major academic cancer center. METHODS: We met with institutional staff to create a PA workflow and process map. We then abstracted pharmacy and medical records for all patients with breast cancer (N = 279) treated at our institution who required a PA between May and November 2015 (324 prescriptions). We examined PA approval rates, time to approval, and associations of these outcomes with the type of medication being prescribed, patient demographics, and method of PA. RESULTS: Seventeen possible process steps and 10 decision points were required for patients to obtain medications requiring a PA. Of the 324 PAs tracked, 316 (97.5%) were approved on the first PA request after an average time of 0.82 days (range, 0 to 14 days). Approximately half of PAs were for either palbociclib (26.5%) or pegfilgrastim (22.2%), and 13.6% of PAs were for generic hormonal therapy. Requirements to fax PA requests were associated with greater delay in approval time (1.31 v 0.17 days for online requests; P < .001). The use of specialty pharmacies increased staff burden and delays in medication receipt. CONCLUSION: The PA process is complicated and labor intensive. Given the high PA approval rate, it is unlikely that PA requirements reduce medication utilization in practice, and these requirements may impose unnecessary burdens on patient care. The goals and requirements for PAs should be readdressed.

Pulmonary hypertension in sickle cell disease.

BACKGROUND: Recurrent vaso-occlusive episodes lead to progressive end-organ damage in patients with sickle cell disease. We sought to determine the prevalence of pulmonary hypertension in adult patients with sickle cell disease and to identify factors associated with this life-threatening complication. METHODS: Sixty patients (> or =18 years of age; mean [+/- SD] age, 37 +/- 13 years) followed at a University Medical Center were evaluated. They were selected by a systematic sampling of patients presenting to the clinic for routine follow-up visits. All enrolled subjects underwent a clinical examination, Doppler echocardiography, pulmonary function tests, and hematologic tests during a single visit. Pulmonary hypertension was defined using an age- and body mass index-adjusted nomogram. RESULTS: The prevalence of pulmonary hypertension was 30% (18/60). Ten patients had mild pulmonary hypertension (up to 44 mm Hg), 5 had moderate pulmonary hypertension (45 to 74 mm Hg), and 2 had severe pulmonary hypertension (> or =75 mm Hg). In a logistic regression model, both lower fetal hemoglobin level and lower systolic blood pressure were associated with the presence of pulmonary hypertension. CONCLUSION: We found that the prevalence of pulmonary hypertension in adult patients with sickle cell disease was substantial, particularly in those with lower levels of fetal hemoglobin and lower systolic blood pressure.

Identification of mutations in a candidate dengue 4 vaccine strain 341750 PDK20 and construction of a full-length cDNA clone of the PDK20 vaccine candidate.

Dengue 4 virus strain 341750 serially passaged 20 times in primary dog kidney (PDK) cells was shown to have reduced infectivity for rhesus monkeys but was immunogenic and protected the monkeys from challenge with low passage parent dengue 4 virus. The dengue 4 PDK20 virus was also shown to be attenuated for human volunteers. We compared the genomic nucleotide sequences of low passage parent and PDK20 attenuated vaccine strains and identified 11 nucleotide (nt) substitutions in the PDK20 genome. Five mutations caused amino acid changes in viral proteins E (N366N/S), NS1 (E146Q), NS4B (S/L112L and A240V), and NS5 (F/L790L). Silent mutations occurred in genes encoding NS1 (nt 2609), NS3 (nt 6113, 6230 and 6239) and NS5 (nt 8081 and 8588). A full-length cDNA clone of the dengue 4 strain 341750 PDK20 was constructed and RNA transcripts of the clone were infectious in monkey kidney (LLC-MK(2)) and Aedes albopictus (C6/36) cells. The sequence analysis and availability of an infectious clone provide molecular tools to investigate the basis for the attenuation of dengue 4 virus.

Dengue virus infection promotes translocation of high mobility group box 1 protein from the nucleus to the cytosol in dendritic cells, upregulates cytokine production and modulates virus replication.

High mobility group box 1 (HMGB1) protein functions in regulation of transcription, cellular activation and pro-inflammatory responses. However, the potential role of HMGB1 during viral infection has not been investigated. This study attempted to elucidate whether the HMGB1-mediated inflammatory response contributes to the pathogenesis of dengue virus (DENV) infection. Our data showed that HMGB1 was released at low DENV infection levels (m.o.i. of 1) under non-necrotic conditions by human dendritic cells (DCs). When DENV-infected DCs were co-cultured with autologous T cells, there was increased production of HMGB1 by both cell types. HMGB1 regulated tumour necrosis factor alpha, interleukin (IL)-6, IL-8 and alpha interferon secretion in DENV-infected DCs. Additionally, increased HMGB1 production was associated with reduced DENV replication titres in DCs. These results suggest that HMGB1 production influences DENV infection in susceptible hosts.

Phosphomimetic mutations increase phospholamban oligomerization and alter the structure of its regulatory complex.

To investigate the effect of phosphorylation on the interactions of phospholamban (PLB) with itself and its regulatory target, SERCA, we measured FRET from CFP-SERCA or CFP-PLB to YFP-PLB in live AAV-293 cells. Phosphorylation of PLB was mimicked by mutations S16E (PKA site) or S16E/T17E (PKA+CaMKII sites). FRET increased with protein concentration up to a maximum (FRET(max)) that was taken to represent the intrinsic FRET of the bound complex. The concentration dependence of FRET yielded dissociation constants (K(D)) for the PLB-PLB and PLB-SERCA interactions. PLB-PLB FRET data suggest pseudo-phosphorylation of PLB increased oligomerization of PLB but did not alter PLB pentamer quaternary structure. PLB-SERCA FRET experiments showed an apparent decrease in binding of PLB to SERCA and an increase in the apparent PLB-SERCA binding cooperativity. It is likely that these changes are secondary effects of increased oligomerization of PLB; a change in the inherent affinity of monomeric PLB for SERCA was not detected. In addition, PLB-SERCA complex FRET(max) was reduced by phosphomimetic mutations, suggesting the conformation of the regulatory complex is significantly altered by PLB phosphorylation.

Phospholamban oligomerization, quaternary structure, and sarco(endo)plasmic reticulum calcium ATPase binding measured by fluorescence resonance energy transfer in living cells.

Phospholamban (PLB) oligomerization, quaternary structure, and sarco(endo)plasmic reticulum calcium ATPase (SERCA) binding were quantified by fluorescence resonance energy transfer (FRET) in an intact cellular environment. FRET between cyan fluorescent protein-PLB and yellow fluorescent protein-PLB in AAV-293 cells showed hyperbolic dependence on protein concentration, with a maximum efficiency of 45.1 +/- 1.3%. The observed FRET corresponds to a probe separation distance of 58.7 +/- 0.5A(,) according to a computational model of intrapentameric FRET. This is consistent with models of the PLB pentamer in which cytoplasmic domains fan out from the central bundle of transmembrane helices. An I40A mutation of PLB did not alter pentamer conformation but increased the concentration of half-maximal FRET (K(D)) by >4-fold. This is consistent with the previous observation that this putatively monomeric mutant still oligomerizes in intact membranes but forms more dynamic pentamers than wild type PLB. PLB association with SERCA, measured by FRET between cyan fluorescent protein-SERCA and yellow fluorescent protein-PLB, was increased by the I40A mutation without any detectable change in probe separation distance. The data indicate that the regulatory complex conformation is not altered by the I40A mutation. A naturally occurring human mutation (L39Stop) greatly reduced PLB oligomerization and SERCA binding and caused mislocalization of PLB to the cytoplasm and nucleus. Overall, the data suggest that the PLB pentamer adopts a "pinwheel" shape in cell membranes, as opposed to a more compact "bellflower" conformation. I40A mutation decreases oligomerization and increases PLB binding to SERCA. Truncation of the transmembrane domain by L39Stop mutation prevents anchoring of the protein in the membrane, greatly reducing PLB binding to itself or its regulatory target, SERCA.