A comprehensive profiling of the immune microenvironment of breast cancer brain metastases.

BACKGROUND: Despite potential clinical implications, the complexity of breast cancer (BC) brain metastases (BM) immune microenvironment is poorly understood. Through multiplex immunofluorescence, we here describe the main features of BCBM immune microenvironment (density and spatial distribution) and evaluate its prognostic impact. METHODS: Sixty BCBM from patients undergoing neurosurgery at three institutions (2003-2018) were comprehensively assessed using two multiplex immunofluorescence panels (CD4, CD8, Granzyme B, FoxP3, CD68, pan-cytokeratin, DAPI; CD3, PD-1, PD-L1, LAG-3, TIM-3, CD163, pan-cytokeratin, DAPI). The prognostic impact of immune subpopulations and cell-to-cell spatial interactions was evaluated. RESULTS: Subtype-related differences in BCBM immune microenvironment and its prognostic impact were observed. While in HR-/HER2- BM and HER2+ BM, higher densities of intra-tumoral CD8+ lymphocytes were associated with significantly longer OS (HR 0.16 and 0.20, respectively), in HR+/HER2- BCBMs a higher CD4+FoxP3+/CD8+ cell ratio in the stroma was associated with worse OS (HR 5.4). Moreover, a higher density of intra-tumoral CD163+ M2-polarized microglia/macrophages in BCBMs was significantly associated with worse OS in HR-/HER2- and HR+/HER2- BCBMs (HR 6.56 and 4.68, respectively), but not in HER2+ BCBMs. In HER2+ BCBMs, multiplex immunofluorescence highlighted a negative prognostic role of PD-1/PD-L1 interaction: patients with a higher percentage of PD-L1+ cells spatially interacting with (within a 20 µm radius) PD-1+ cells presented a significantly worse OS (HR 4.60). CONCLUSIONS: Our results highlight subtype-related differences in BCBM immune microenvironment and identify two potential therapeutic targets, M2 microglia/macrophage polarization in HER2- and PD-1/PD-L1 interaction in HER2+ BCBMs, which warrant future exploration in clinical trials.

N95 respirator reuse, decontamination methods, and microbial burden: A randomized controlled trial.

PURPOSE: To evaluate the effectiveness and ease of N95 respirator decontamination methods in a clinic setting and to identify the extent of microbial colonization on respirators associated with reuse. METHODS: In a prospective fashion, N95 respirators (n = 15) were randomized to a decontamination process (time, dry heat, or ultraviolet C light [UVC]) in outpatient clinics. Each respirator was re-used up to 5 separate clinic sessions. Swabs on each respirator for SARS-CoV-2, bacteria, and fungi were obtained before clinic, after clinic and post-treatment. Mask integrity was checked after each treatment (n = 68). Statistical analyses were performed to determine factors for positive samples. RESULTS: All three decontamination processes reduced bacteria counts similarly. On multivariate mixed model analysis, there were an additional 8.1 colonies of bacteria (95% CI 5.7 to 10.5; p < 0.01) on the inside compared to the outside surface of the respirators. Treatment resulted in a decrease of bacterial load by 8.6 colonies (95% CI -11.6 to -5.5; p < 0.01). Although no decontamination treatment affected the respirator filtration efficiency, heat treatments were associated with the breakdown of thermoplastic elastomer straps. Contamination with fungal and SARS-CoV-2 viral particles were minimal to non-existent. CONCLUSIONS: Time, heat and UVC all reduced bacterial load on reused N95 respirators. Fungal contamination was minimal. Heat could permanently damage some elastic straps making the respirators nonfunctional. Given its effectiveness against microbes, lack of damage to re-treated respirators and logistical ease, UVC represents an optimal decontamination method for individual N95 respirators when reuse is necessary.

Invasion in thyroid cancer: Controversies and best practices.

Invasion is a key feature of malignancy and an important element in the classification, risk-stratification, and staging of thyroid cancers. However, the histopathologic criteria for tumor capsular invasion, angioinvasion, and extrathyroidal extension (ETE) have varied among pathologists, both in practice as well as in studies assessing the clinical significance of these findings. In this review, we provide historic context for the controversies surrounding the definition of invasion in thyroid neoplasms and highlight recent efforts to standardize how pathologists report capsular invasion, angioinvasion, and ETE. We offer practical suggestions for distinguishing invasion from its mimics and provide an algorithmic approach for classifying thyroid tumors based on integration of tumor invasiveness, nuclear atypia, and architectural pattern.

Two-Year Outcomes of Infants with Stage 2 or Higher Retinopathy of Prematurity: Results from a Large Multicenter Registry.

OBJECTIVE: To define the incidence of ophthalmologic morbidities in the first 2 years of life among infants diagnosed with stage 2 or higher retinopathy of prematurity (ROP). STUDY DESIGN: We prospectively enrolled premature infants with stage 2 or higher ROP. The infants were followed up for 2 years, and we report on data collected from outpatient ophthalmology and primary care visits. RESULTS: We enrolled 323 infants who met inclusion criteria, of which 112 (35%) received treatment with laser surgery (90) or bevacizumab (22). Two-year follow-up was available for 292 (90%) of the cohort. The most common ophthalmologic conditions at follow-up were hyperopia (35%), astigmatism (30%), strabismus (21.9%), myopia (19.2%), anisometropia (12%), and amblyopia (12%). Severe ophthalmologic morbidities such as retinal detachment and cataracts were rare, but occurred in both treated and untreated infants. Overall, 22.6% of the infants were wearing glasses at 2 years, including 8.5% of the untreated infants. CONCLUSION: Patients with stage 2 or higher ROP remain at significant risk for ophthalmological morbidity through 2 years of age. Infants with regression of subthreshold ROP who do not require treatment represent an underrecognized population at long-term ophthalmological risk. CLINICALTRIALS. GOV IDENTIFIER: NCT01559571.

Training the Next Generation of Pathologists: A Novel Residency Program Curriculum at Montefiore Medical Center/Albert Einstein College of Medicine.

Pathology residency training is currently a time-intensive process, frequently extending up to 6 years in duration as residents complete 1 or 2 fellowships following graduation. Innovative training curricula may help address the impending changes in the health-care landscape, particularly future shortfalls in pathology staffing and changing health-care models that incorporate more work within interdisciplinary teams. Montefiore has created a novel residency training program aimed at accelerating the acquisition of competency in pathology, preparing residents for independent practice at the completion of residency training, and providing residents with the requisite adaptability and consultative skills to excel wherever they choose to practice. We describe the implementation of this novel pathology residency training curriculum at Montefiore Medical Center/Albert Einstein College of Medicine and the perception of residents in both the old curriculum and the new curriculum.

Fetal-Not Maternal-APOL1 Genotype Associated with Risk for Preeclampsia in Those with African Ancestry.

Black Americans are at increased risk for preeclampsia. Genetic variants in apolipoprotein L1 (APOL1) account for much of the increased risk for kidney disease in blacks. APOL1 is expressed in human placenta and transgenic mice expressing APOL1 develop preeclampsia. We evaluated the role of APOL1 variants in human preeclampsia. We determined maternal and fetal APOL1 genotypes in black women with preeclampsia in two populations. At Einstein Montefiore Center (EMC) Affiliated Hospitals, we studied 121 pregnancies in black women with preeclampsia. At University of Tennessee Health Science Center (UTHSC), we studied 93 pregnancies in black women with preeclampsia and 793 pregnancies without preeclampsia. We measured serum markers of preeclampsia soluble fms-like tyrosine kinase 1 (sFlt-1), placental growth factor (PlGF), and soluble endoglin (sEng). Fetal APOL1 high-risk (HR) genotype was associated with preeclampsia, with odds ratios at EMC and UTHSC of 1.84 (95% CI 1.11, 2.93) and 1.92 (95% CI 1.05, 3.49), respectively. Maternal APOL1 HR genotype was not associated with preeclampsia. Mothers with the fetal APOL1 HR genotype had more cerebral or visual disturbances (63% versus 37%, p = 0.04). In addition, fetal APOL1 HR genotype was associated with a higher sFLT-1/PlGF ratio at birth (p = 0.04). Fetal APOL1 high-risk genotype increases the risk for preeclampsia, likely by adversely affecting placental function. Further research is needed to assess whether APOL1 genetic testing can predict preeclampsia and improve pregnancy outcomes.

Factors associated with retinopathy of prematurity ophthalmology workload.

OBJECTIVE: This article reports on retinopathy of prematurity (ROP) workload in the NICU related to severity of disease, gestational age at discharge, and practice variation. STUDY DESIGN: Data analysis on 1771 patients ≤ 30 weeks of gestation at birth from a de-identified data set of 13 NICUs. RESULTS: There was a positive relationship between the severity of ROP and (1) the number of exams per patient, (2) the severity of ROP, and (3) postmenstrual age at discharge. The progression between the stages of ROP added to exam workload and postmenstrual age at NICU discharge. The addition of plus disease did not increase the exam burden. There was significant practice variation in the number of exams performed independent of ROP severity. CONCLUSION: The progression of the severity of ROP independent of plus disease, and practice variations both contribute to ROP workload. Addressing these factors could decrease ROP workload without compromising American Academy of Pediatrics (AAP) guidelines.

Holocrine Poroma: A Distinctive Adnexal Tumor.

There are 36 cases of complex poroid tumors with folliculosebaceous and apocrine differentiation reported in the literature. The authors evaluated 111 poroid tumors including 63 typical eccrine poromas and 48 poroid tumors with folliculosebaceous elements. Folliculosebaceous poroid tumors (FSPT) had basaloid and squamous cells (100%), ducts with steatocystoma-like cuticles and holocrine secretions (89.6%), infundibular follicular structures (66.7%), and entrapped sebocytes (56.3%). No definite apocrine decapitation secretions in FSPT were found. Immunohistochemistry was strongly positive for CK903 and focally positive for CAM5.2, epithelial membrane antigen, and carcinoembryonic antigen. No loss of MLH-1, MSH-2, or MSH-6 mismatch repair proteins was found. FSPT had distinctive features that differentiate them from eccrine poromas including the frequent head and neck locations (62.5% vs. 20.6%, P < 0.01), squamous cytology (100% vs. 1.6%, P < 0.01), more prominent cytoplasmic vacuolization (score 1.4/4.0 vs. 0.3/4.0, P < 0.01), presence of infundibular follicular structures (score 1.2/4.0 vs. 0.03/4.0, P < 0.01), presence of ducts with steatocystoma-like cuticles (89.6% vs. 0.0%, P < 0.01), and less stromal hyalinization (score 1.0/4.0 vs. 2.5/4.0, P < 0.01). The authors propose that FSPT are distinctive benign tumors originating from the sebaceous gland duct and are therefore best categorized as holocrine poroma.

Particle dispersion in porous media: Differentiating effects of geometry and fluid rheology.

We investigate the effects of geometric order and fluid rheology on the dispersion of micron-sized particles in two-dimensional microfluidic porous media. Particles suspended in a mixture of glycerol and water or in solutions of partially hydrolyzed polyacrylamide (HPAM) polymers were imaged as they flowed through arrays of microscale posts. From the trajectories of the particles, we calculated the velocity distributions and thereafter obtained the longitudinal and transverse dispersion coefficients. Particles flowed in the shear-thinning HPAM solution through periodic arrays of microposts were more likely to switch between streamlines, due to elastic instabilities. As a result, the distributions of particle velocity were broader in HPAM solutions than in glycerol-water mixtures for ordered geometries. In a disordered array of microposts, however, there was little difference between the velocity distributions obtained in glycerol-water and in HPAM solutions. Correspondingly, particles flowed through ordered post arrays in HPAM solutions exhibited enhanced transverse dispersion. This result suggests that periodic geometric order amplifies the effects of the elasticity-induced velocity fluctuations, whereas geometric disorder of barriers effectively averages out the fluctuations.

Toward Achieving 100% Adherence for Retinopathy of Prematurity Screening Guidelines.

PURPOSE: To report on the use of a cloud-based electronic medical record (ROP Check; Glacier Medical Software, Anchorage, AK) designed to provide American Academy of Pediatrics (AAP) guideline-adherent retinopathy of prematurity (ROP) care through the scheduling and documenting of ROP examinations. METHODS: Data analysis on 3,155 patients from a de-identified dataset from 13 neonatal intensive care units. RESULTS: All newborns with a gestational age of 22 to 30 weeks (N = 2,278) were entered with a documented ROP examination. Of those, 98% and 97.4% completed their initial and follow-up examinations, respectively, within AAP guidelines. All but 1 of 145 initial treatments were completed within AAP guidelines after a decision for treatment was made. Of 369 newborns older than 30 weeks' gestational age and with a birth weight of less than 1,500 grams, none progressed to treatment; four patients had stage 2 or 3 ROP. Of 508 newborns with a gestational age of 31 to 32 weeks and a birth weight of more than 1,500 grams who were entered to identify unstable newborns, 34% did not need examinations; of those who were examined, one progressed to treatment. Fourteen percent of patients were observed as outpatients before retinal maturity and 12% missed some or all outpatient appointments. A decision was made to treat at the first examination for 2 (10%) newborns with a gestational age of 22 weeks and 2 (2%) newborns with a gestational age of 23 weeks. Each patient was within the AAP guidelines for initial treatment. CONCLUSIONS: A computerized system specifically designed with process improvement and error-free delivery of ROP care as a focus can improve adherence to AAP guidelines and achieve superior results. Such a system creates a standardized and measurable safety net for pediatric ophthalmologists, neonatologists, hospitals, and follow-up pediatricians. [J Pediatr Ophthalmol Strabismus. 2017;54(6):356-362.].

Outpatient, Wide-Field, Digital Imaging of Infants With Retinopathy of Prematurity.

Eight infants were closely monitored for retinopathy of prematurity (ROP) while in the neonatal intensive care unit (NICU); two required laser therapy. After discharge from the NICU, they had outpatient examination with dilated, scleral depressed ROP staging, and each had digital widefield retinal imaging (Optos, Dunfermline, United Kingdom) without lid speculum, or with lid speculum if not cooperative. Images were shared remotely using ROP-Check software (Glacier Medical Software, Anchorage, AK), from which ophthalmologists made clinical impressions. The images did not afford clear view of maturity to the ora serrata; however, posterior zone 3 was viewed, and confirmation that each eye did not need therapy was consistent. Outpatient wide-field retinal imaging may help facilitate telemedicine for ROP. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:494-497.].

#InSituPathologists: how the #USCAP2015 meeting went viral on Twitter and founded the social media movement for the United States and Canadian Academy of Pathology.

Professional medical conferences over the past five years have seen an enormous increase in the use of Twitter in real-time, also known as "live-tweeting". At the United States and Canadian Academy of Pathology (USCAP) 2015 annual meeting, 24 attendees (the authors) volunteered to participate in a live-tweet group, the #InSituPathologists. This group, along with other attendees, kept the world updated via Twitter about the happenings at the annual meeting. There were 6,524 #USCAP2015 tweets made by 662 individual Twitter users; these generated 5,869,323 unique impressions (potential tweet-views) over a 13-day time span encompassing the dates of the annual meeting. Herein we document the successful implementation of the first official USCAP annual meeting live-tweet group, including the pros/cons of live-tweeting and other experiences of the original #InSituPathologists group members. No prior peer-reviewed publications to our knowledge have described in depth the use of an organized group to "live-tweet" a pathology meeting. We believe our group to be the first of its kind in the field of pathology.

Zn uptake behavior of rice genotypes and its implication on grain Zn biofortification.

Understanding Zn uptake dynamics is critical to rice grain Zn biofortification. Here we examined soil Zn availability and Zn uptake pathways as affected by genotype (high-grain Zn varieties IR69428 and IR68144), Zn fertilization and water management in two pot experiments. Results showed significant interactions (P < 0.05) between genotypes and Zn fertilization on DTPA (diethylenetriaminepentaacetic acid)-extractable soil Zn from early tillering to flowering. DTPA-extractable Zn in soils grown with IR69428 was positively correlated with stem (r = 0.78, P < 0.01), flagleaf (r = 0.60, P < 0.01) and grain (r = 0.67, P < 0.01) Zn concentrations, suggesting improved soil Zn availability and continued soil Zn uptake by IR69428 even at maturity. Conversely for IR68144, DTPA-extractable Zn was positively correlated only with leaf Zn uptake (r = 0.60, P < 0.01) at active tillering, indicating dependence on remobilization for grain Zn loading. Furthermore, the highest grain Zn concentration (P < 0.05) was produced by a combination of IR69428 and Zn fertilization applied at panicle initiation (38.5 µg g-1) compared with other treatments (P < 0.05). The results highlight that Zn uptake behavior of a rice genotype determines the fate of Zn from the soil to the grain. This has implications on overcoming Zn translocation barriers between vegetative parts and grains, and achieving grain Zn biofortification targets (30.0 µg g-1).

Diffusive dynamics of nanoparticles in ultra-confined media.

Differential dynamic microscopy (DDM) was used to investigate the diffusive dynamics of nanoparticles of diameter 200-400 nm that were strongly confined in a periodic square array of cylindrical nanoposts. The minimum distance between posts was 1.3-5 times the diameter of the nanoparticles. The image structure functions obtained from the DDM analysis were isotropic and could be fit by a stretched exponential function. The relaxation time scaled diffusively across the range of wave vectors studied, and the corresponding scalar diffusivities decreased monotonically with increased confinement. The decrease in diffusivity could be described by models for hindered diffusion that accounted for steric restrictions and hydrodynamic interactions. The stretching exponent decreased linearly as the nanoparticles were increasingly confined by the posts. Together, these results are consistent with a picture in which strongly confined nanoparticles experience a heterogeneous spatial environment arising from hydrodynamics and volume exclusion on time scales comparable to cage escape, leading to multiple relaxation processes and Fickian but non-Gaussian diffusive dynamics.

Etiologies of NICU deaths.

BACKGROUND AND OBJECTIVES: Infant mortality is an indicator of overall societal health, and a significant proportion of infant deaths occur in NICUs. The objectives were to identify causes of death and to define potentially preventable factors associated with death as areas for quality improvement efforts in the NICU. METHODS: In a prospectively defined study, the principal investigator in 46 level III NICUs agreed to review health care records of infants who died. For each infant, the principal investigator reviewed the medical record to identify the primary cause of death and to look for preventable factors associated with the infant's death. Infants born at ≥22 weeks estimated gestational age who were born alive were included. Stillborn infants were excluded. RESULTS: Data were collected on 641 infants who died. At lower gestational ages, mortality was most commonly due to extreme prematurity and the complications of premature birth (respiratory distress progressing to respiratory failure, intraventricular hemorrhage, necrotizing enterocolitis, and sepsis). With increasing gestational age, the etiology of mortality shifted to hypoxic-ischemic encephalopathy and genetic or structural anomalies. Reviewers of clinical care identified 197 (31%) infants with potentially modifiable factors that may have contributed to their deaths. CONCLUSIONS: The factors associated with death in infants admitted for intensive care are multifactorial and diverse, and they change with gestational age. In 31% of the deaths, potentially modifiable factors were identified, and these factors suggest important targets for reducing infant mortality.

Congenital toxoplasmosis presenting with fetal atrial flutter after maternal ingestion of infected moose meat.

Consumption of undercooked game meat during pregnancy is considered a risk factor for congenital toxoplasmosis, but cases definitively linking ingestion of infected meat to clinical disease are lacking. We report a confirmed case of congenital toxoplasmosis identified because of atrial flutter in the fetus and linked to maternal consumption of Toxoplasma gondii PCR-positive moose meat.