Long-term efficacy and safety of cardiac genome editing for catecholaminergic polymorphic ventricular tachycardia.

Introduction: Heterozygous autosomal-dominant single nucleotide variants in RYR2 account for 60% of cases of catecholaminergic polymorphic ventricular tachycardia (CPVT), an inherited arrhythmia disorder associated with high mortality rates. CRISPR/Cas9-mediated genome editing is a promising therapeutic approach that can permanently cure the disease by removing the mutant RYR2 allele. However, the safety and long-term efficacy of this strategy have not been established in a relevant disease model. Aim: The purpose of this study was to assess whether adeno-associated virus type-9 (AAV9)-mediated somatic genome editing could prevent ventricular arrhythmias by removal of the mutant allele in mice that are heterozygous for Ryr2 variant p.Arg176Gln (R176Q/+). Methods and Results: Guide RNA and SaCas9 were delivered using AAV9 vectors injected subcutaneously in 10-day-old mice. At 6 weeks after injection, R176Q/+ mice had a 100% reduction in ventricular arrhythmias compared to controls. When aged to 12 months, injected R176Q/+ mice maintained a 100% reduction in arrhythmia induction. Deep RNA sequencing revealed the formation of insertions/deletions at the target site with minimal off-target editing on the wild-type allele. Consequently, CRISPR/SaCas9 editing resulted in a 45% reduction of total Ryr2 mRNA and a 38% reduction in RyR2 protein. Genome editing was well tolerated based on serial echocardiography, revealing unaltered cardiac function and structure up to 12 months after AAV9 injection. Conclusion: Taken together, AAV9-mediated CRISPR/Cas9 genome editing could efficiently disrupt the mutant Ryr2 allele, preventing lethal arrhythmias while preserving normal cardiac function in the R176Q/+ mouse model of CPVT.

Revision Endoscopic Posterior Costal Cartilage Grafting: Is It Feasible?

The objective of this work is to examine the feasibility of revision endoscopic posterior costal cartilage graft (EPCCG) placement for posterior glottic stenosis (PGS) and bilateral vocal fold immobility (BVFI). Revision and primary cases were compared with respect to decannulation rates, and it was hypothesized that there would be no difference in outcomes. Twenty-one patients met inclusion criteria (14 primary, 7 revision). Thirteen (62%) had a primary indication of PGS, and 8 (42%) were for BVFI. There were no differences between revision and primary groups with respect to age, gender, or comorbidities (p > .05). There was no difference between groups with respect to decannulation rate (85% primary vs 100% revision, p = .32). Thus, revision EPCCG appears to have comparable results to primary EPCCG with respect to decannulation rate and time to decannulation. EPCCG may be a feasible alternative to open airway reconstruction for PGS and BVFI in selected patients.

Osteosarcoma in the Thyroid Gland.

Primary osteosarcomas are rarely seen in areas other than bone, although they can occur in sites such as the thigh, anal region, hand, etc. We present a case of primary extraskeletal osteosarcoma of the thyroid, of which there are only 29 previous reported cases. Presentations and treatment options for this type of tumor vary. Through this case report, we discuss the similarities and differences of the patient's presentation compared with other documented cases, imaging, the rationale behind treatment, and the current clinical course.

CYP27A1-dependent anti-melanoma activity of limonoid natural products targets mitochondrial metabolism.

Three limonoid natural products with selective anti-proliferative activity against BRAF(V600E) and NRAS(Q61K)-mutation-dependent melanoma cell lines were identified. Differential transcriptome analysis revealed dependency of compound activity on expression of the mitochondrial cytochrome P450 oxidase CYP27A1, a transcriptional target of melanogenesis-associated transcription factor (MITF). We determined that CYP27A1 activity is necessary for the generation of a reactive metabolite that proceeds to inhibit cellular proliferation. A genome-wide small interfering RNA screen in combination with chemical proteomics experiments revealed gene-drug functional epistasis, suggesting that these compounds target mitochondrial biogenesis and inhibit tumor bioenergetics through a covalent mechanism. Our work suggests a strategy for melanoma-specific targeting by exploiting the expression of MITF target gene CYP27A1 and inhibiting mitochondrial oxidative phosphorylation in BRAF mutant melanomas.

A review of the efficacy of a low-cost cancer screening test using cancer sniffing canines.

One of the most powerful tools in fighting cancer is early detection, as it has been strongly linked to greater chances of cancer survival. However, traditional cancer screening tests can cost hundreds if not thousands of dollars and are therefore not an affordable option for many marginalized populations. From a public health perspective, it is vital to research the use of inexpensive cancer detection so that low-resourced patients have greater access to affordable cancer screening. Numerous studies dating from the early 2000s to recent years have shown extensive evidence that the exceptional olfactory system of canines allows them to detect certain odors through exhaled breath condensate that are known to be biomarkers of a variety of cancers. In addition to providing a cheaper alternative to conventional cancer screening tests, the use of cancer sniffing dogs has other benefits, including great reliability and accuracy. There are a few major types of cancer for which the 'cancer dog test' proved to be remarkably effective, particularly colorectal, ovarian, and lung cancers. The test is non-invasive unlike most previous detection methods, meaning that it is also a safer option for individuals seeking cancer screening. Although the use of cancer sniffing dogs does have certain limitations and scope for error, it would provide a more affordable and accessible option for cancer screening, making it especially beneficial to low-resourced populations.

Prioritizing Diversity in Otolaryngology-Head and Neck Surgery: Starting a Conversation.

Academic centers embody the ideals of otolaryngology and are the specialty's port of entry. Building a diverse otolaryngology workforce-one that mirrors society-is critical. Otolaryngology continues to have an underrepresentation of racial and ethnic minorities. The specialty must therefore redouble efforts, becoming more purposeful in mentoring, recruiting, and retaining underrepresented minorities. Many programs have never had residents who are Black, Indigenous, or people of color. Improving narrow, leaky, or absent pipelines is a moral imperative, both to mitigate health care disparities and to help build a more just health care system. Diversity supports the tripartite mission of patient care, education, and research. This commentary explores diversity in otolaryngology with attention to the salient role of academic medical centers. Leadership matters deeply in such efforts, from culture to finances. Improving outreach, taking a holistic approach to resident selection, and improving mentorship and sponsorship complement advances in racial disparities to foster diversity.

Case Series on 2g Tranexamic Acid Flush From the 75th Ranger Regiment Casualty Database.

Early tranexamic acid (TXA) administration for resuscitation of critically injured warfighters provides a mortality benefit. The 2019 Tactical Combat Casualty Care (TCCC) recommendations of a 1g drip over 10 minutes, followed by 1g drip over 8 hours, is intended to limit potential TXA side effects, including hypotension, seizures, and anaphylaxis. However, this slow and cumbersome TXA infusion protocol is difficult to execute in the tactical care environment. Additionally, the side effect cautions derive from studies of elderly or cardiothoracic surgery patients, not young healthy warfighters. Therefore, the 75th Ranger Regiment developed and implemented a 2g intravenous or intraosseous (IV/IO) TXA flush protocol. We report on the first six cases of this protocol in the history of the Regiment. After-action reports (AARs) revealed no incidences of post-TXA hypotension, seizures, or anaphylaxis. Combined, the results of this case series are encouraging and provide a foundation for larger studies to fully determine the safety of the novel 2g IV/IO TXA flush protocol toward preserving the lives of traumatically injured warfighters.

The influence of flowrate and gas density on positive airway pressure for high flow nasal cannula applied to infant airway replicas.

High flow nasal cannula (HFNC) therapy has been previously shown to produce positive upper airway pressures in adult and child patients. This work aimed to evaluate and quantify the effects of HFNC flowrate and gas type on airway pressures measured in vitro in infant airway replicas. Ten realistic infant airway replicas, extending from nares to trachea, were connected in turn to a lung simulator and were supplied gas flows through HFNC. Air and heliox were each provided at two weight-indexed flowrates, 1 l/min/kg and 2 l/min/kg. Pressure and lung volume were continuously measured during simulated breathing. For constant simulated patient effort, no statistically significant change in tidal volume was measured between baseline and lower or higher HFNC flowrates, nor was there any significant difference in tidal volume between air and heliox. Tracheal pressure increased with increasing HFNC flow rate, and was highly variable between airway replicas. Higher pressures were measured for air versus heliox. For air supplied at 2 l/min/kg, average airway pressures in excess of 4 cm H2O were generated, with positive end-expiratory pressure (PEEP) ranging from 2.5 to nearly 12 cm H2O across the replicas. A predictive correlation for PEEP was proposed based on supplied gas density and flow velocities exiting the cannula and nares, and was able to account for a portion of variability between airway replicas (R2 = 0.913). Additionally, PEEP was well correlated with, and predictive of, expiratory peak pressure (R2 = 0.939) and average inspiratory pressure (R2 = 0.944).

COVID-19 pandemic and health care disparities in head and neck cancer: Scanning the horizon.

The COVID-19 pandemic has profoundly disrupted head and neck cancer (HNC) care delivery in ways that will likely persist long term. As we scan the horizon, this crisis has the potential to amplify preexisting racial/ethnic disparities for patients with HNC. Potential drivers of disparate HNC survival resulting from the pandemic include (a) differential access to telemedicine, timely diagnosis, and treatment; (b) implicit bias in initiatives to triage, prioritize, and schedule HNC-directed therapy; and (c) the marked changes in employment, health insurance, and dependent care. We present four strategies to mitigate these disparities: (a) collect detailed data on access to care by race/ethnicity, income, education, and community; (b) raise awareness of HNC disparities; (c) engage stakeholders in developing culturally appropriate solutions; and (d) ensure that surgical prioritization protocols minimize risk of racial/ethnic bias. Collectively, these measures address social determinants of health and the moral imperative to provide equitable, high-quality HNC care.

Microplastics: Sources and distribution in surface waters and sediments of Todos Santos Bay, Mexico.

Microplastics (MPs) are ubiquitous and a threat to marine and freshwater environments. Effluent waters from secondary wastewater treatment plants (WWTPs) into Todos Santos Bay (TSB) were investigated as sources of MPs. MPs were detected in all analyzed matrices and presented variable morphologies. MPs from surface water samples (n = 18) varied from 0.01 to 0.70 plastic particles/m3 (pp/m3). Fragments (47 ±â€¯23%) and fibers (47 ±â€¯23%) were the most abundant particles found in the surface water samples. In sediment samples (n = 11), MPs varied from 85 to 2494 pp/0.1 m2. Sediment samples showed fragments of 70 ±â€¯19%, fibers 28 ±â€¯18% in mean. The range of MP values from WWTP effluents (n = 24) was 81 to 1556 pp/m3, and fibers (65 ±â€¯28%) were the most abundant MP particles. Several synthetic polymers (polypropylene, polyethylene, polyethylene-propylene, polyvinyl chloride, cellophane), and natural fibers (cotton and wood) were identified. The surface currents and the parameters that modulate them, are the main factors that dominate the distribution of MPs in surface waters. While in the sediments the parameters such as bathymetry and grain size distribution have more influence on their distribution in the marine environment, where the effluent waters from WWTPs only contributes MPs to the TSB.

Correlation of high flow nasal cannula outlet area with gas clearance and pressure in adult upper airway replicas.

BACKGROUND: Primary benefits of high flow nasal cannula therapy include washout of carbon dioxide rich exhaled gas and increased airway pressures during tidal breathing. This work reports on the influence of high flow nasal cannula outlet area on upper airways gas clearance and tracheal pressures using measurements in five realistic adult nose-throat airway replicas. METHODS: Two commercial high flow nasal cannulas and one generic nasal cannula of varying size were compared. 100% oxygen was supplied via cannulas at flow rates ranging from 30 to 90l/min to replicas originally filled with air, and oxygen concentrations at the larynx and trachea were compared over time. Additionally, and separately, replicas were connected to a mechanical lung simulator to simulate tidal breathing while undergoing high flow nasal cannula therapy, with tracheal pressure-time waveforms recorded. FINDINGS: Faster gas clearance corresponded with higher flow rates (P<0.001), and with smaller cannula outlet area (P<0.001). Observed pressures were in approximate agreement with limited available in-vivo data in the literature. Between 0 and 60L/min cannula flow rates, tracheal positive end expiratory pressures increase was greater with the smallest cannula (∆PPEEP=785SD(185) Pa) compared to the largest cannula (∆PPEEP=380SD(120)Pa). Regression analysis indicates that positive end expiratory pressure is proportional to the square of flow velocities exiting the cannula and nares (R2=0.906). INTERPRETATION: Since increased pressure and clearance rate have been associated with improved clinical outcomes in previous studies, our results suggest that smaller cannula outlet area may be preferable.

HLA class I antigen processing machinery (APM) component expression and PD-1:PD-L1 pathway activation in HIV-infected head and neck cancers.

Human immunodeficiency virus (HIV)-infected individuals are at increased risk for developing several non-AIDS related malignancies and are often excluded from cancer immunotherapy regimens. To evaluate the immune competence of this cancer patient population, we evaluated HLA class I antigen presenting machinery (APM) component expression and PD-1:PD-L1 pathway upregulation in HIV(+) and HIV(-) head and neck cancers (HNCs). Sixty-two HIV(+) and 44 matched HIV(-) controls diagnosed with HNC between 1991 and 2011 from five tertiary care referral centers in the United States were identified. HLA class I APM component, PD-1, and PD-L1 expression were analyzed by immunohistochemical staining with monoclonal antibodies (mAbs). Clinical data was abstracted from the medical records. There was no significant difference between the cases and controls in LMP2, TAP1, HLA-A and HLA-B/C, as well as PD-1 and PD-L1 expression. Overall, 62% of all subjects had high PD-1 expression and 82% of the subjects expressed PD-L1 within the tumor microenvironment. LMP2, HLA-A and HLA-B/C expression were significantly associated with moderate to high PD-1 expression in the HIV(+) HNC cases (p = .004, p = .026, and p = .006, respectively) but not in the HIV(-) controls. In addition, HLA-A expression was significantly associated with PD-L1 expression in the HIV(+) HNC cases only (p = .029). HIV-infected individuals diagnosed with HNC do not have any detectable defects in HLA class I APM component expression and in PD-1:PD-L1 pathway activation. Given the current successes of HAART therapy in maintaining immune cell counts, HIV(+) patients diagnosed with cancer may benefit from the recently FDA-approved immune checkpoint blockade therapy.

Prognostic biomarkers in patients with human immunodeficiency virus-positive disease with head and neck squamous cell carcinoma.

BACKGROUND: We examined the prognostic value of a panel of biomarkers in patients with squamous cell carcinoma of the head and neck (SCCHN) who were human immunodeficiency virus (HIV) positive (HIV-positive head and neck cancer) and HIV negative (HIV-negative head and neck cancer). METHODS: Tissue microarrays (TMAs) were constructed using tumors from 41 disease site-matched and age-matched HIV-positive head and neck cancer cases and 44 HIV-negative head and neck cancer controls. Expression of tumor biomarkers was assessed by immunohistochemistry (IHC) and correlations examined with clinical variables. RESULTS: Expression levels of the studied oncogenic and inflammatory tumor biomarkers were not differentially regulated by HIV status. Among patients with HIV-positive head and neck cancer, laryngeal disease site (P = .003) and Clavien-Dindo classification IV (CD4) counts <200 cells/µL (P = .01) were associated with poor prognosis. Multivariate analysis showed that p16 positivity was associated with improved overall survival (OS; P < .001) whereas increased expression of transforming growth factor-beta (TGF-ß) was associated with poor clinical outcome (P = .001). CONCLUSION: Disease site has significant effect on the expression of biomarkers. Expression of tumor TGF-ß could be a valuable addition to the conventional risk stratification equation for improving head and neck cancer disease management strategies.

The Mediterranean Plastic Soup: synthetic polymers in Mediterranean surface waters.

The Mediterranean Sea has been recently proposed as one of the most impacted regions of the world with regards to microplastics, however the polymeric composition of these floating particles is still largely unknown. Here we present the results of a large-scale survey of neustonic micro- and meso-plastics floating in Mediterranean waters, providing the first extensive characterization of their chemical identity as well as detailed information on their abundance and geographical distribution. All particles >700 µm collected in our samples were identified through FT-IR analysis (n = 4050 particles), shedding for the first time light on the polymeric diversity of this emerging pollutant. Sixteen different classes of synthetic materials were identified. Low-density polymers such as polyethylene and polypropylene were the most abundant compounds, followed by polyamides, plastic-based paints, polyvinyl chloride, polystyrene and polyvinyl alcohol. Less frequent polymers included polyethylene terephthalate, polyisoprene, poly(vinyl stearate), ethylene-vinyl acetate, polyepoxide, paraffin wax and polycaprolactone, a biodegradable polyester reported for the first time floating in off-shore waters. Geographical differences in sample composition were also observed, demonstrating sub-basin scale heterogeneity in plastics distribution and likely reflecting a complex interplay between pollution sources, sinks and residence times of different polymers at sea.

Results of topography-guided laser in situ keratomileusis custom ablation treatment with a refractive excimer laser.

PURPOSE: To evaluate the safety and effectiveness of topography-guided custom ablation treatment (T-CAT) to correct myopia and myopic astigmatism with laser in situ keratomileusis (LASIK). SETTING: Nine clinical sites in the USA. DESIGN: Prospective observational nonrandomized unmasked study. METHODS: The study comprised patients aged 18 to 65 years old with myopia or myopic astigmatism with a manifest refraction spherical equivalent (MRSE) up to -9.0 diopters (D) and astigmatism of 6.0 D or less. Patients with previous refractive surgery or abnormal topography were excluded. Corneal topographies were obtained using the Allegro Topolyzer, and laser treatment was delivered with the Allegretto Wave Eye-Q excimer laser system. Visual outcomes were evaluated postoperatively at 1 day, 1 week, and 1, 3, 6, 9, and 12 months. RESULTS: The clinical trial enrolled 212 patients (249 eyes). The T-CAT procedure significantly reduced the MRSE and cylinder, with stability of outcomes evident from 3 to 12 months after surgery. Compared with the preoperative corrected distance visual acuity (CDVA), the postoperative uncorrected distance visual acuity (UDVA) improved by 1 line or more in 30% of eyes and the postoperative UDVA was at least as good as the preoperative CDVA in 90% of eyes. Most visual symptoms improved after T-CAT. There were no significant treatment-related adverse events or loss of vision. CONCLUSION: The T-CAT procedure performed with the diagnostic device and the refractive excimer laser system safely and effectively achieved predictable refractive outcomes and reduced visual symptoms with stable results through 12 months. FINANCIAL DISCLOSURE: Dr. Stulting is a paid consultant to Alcon Laboratories, Inc., and was a medical monitor for the U.S. Food and Drug Administration (FDA) clinical trial. Dr. Fant is president of Clinical Research Consultants, Inc. (CRC), the clinical and regulatory consulting group that sponsored the FDA clinical trial. Dr. Fant and CRC were supported by Alcon Laboratories, Inc.

Interobserver agreement of confocal laser endomicroscopy for detection of head and neck neoplasia.

OBJECTIVES/HYPOTHESIS: We have described the feasibility of using the probe-based confocal laser endomicroscopy (pCLE) in differentiating benign from malignant lesions of the head and neck. Therefore, we wanted to determine the interobserver agreement of pCLE offline images of noncancerous, precancerous, and cancerous lesions of the head and neck. STUDY DESIGN: Single tertiary referral center. METHODS: In the feasibility study, image criteria for nondysplasia, dysplasia, and cancer were defined. The pCLE was performed before lesions were biopsied. Fifty offline images and 10 videos of good quality were selected. Seven surgeons and one pathologist were asked to review and categorize the images into the three categories above. The overall accuracy of 29 offline pCLE images and six videos were compared with histopathology. Interobserver agreement and accuracy kappa (κ) scores were measured with 95% confidence intervals (CI). RESULTS: There were six nondysplasia, seven dysplasia, and 11 squamous cell carcinoma (SCCA) cases, each with multiple images. There was substantial agreement between the eight reviewers on the pCLE images and videos (κ = 0.66; 95% CI 0.51-0.82 and κ = 0.71; 95% CI 0.42-0.97, respectively). The overall agreement with the final histopathology was also substantial for both the images and video sequences (κ = 0.70; 95% CI 0.50-0.88 and κ = 0.73; 95% CI 0.39-1.00, respectively). CONCLUSION: The ability to differentiate normal mucosa, dysplasia, and invasive SCCA using pCLE with high accuracy and reliability was demonstrated. This technology has the potential to decrease sampling error of lesions in the head and neck. This is the first study to test the reliability of this technology in mucosal lesions of the head and neck. LEVEL OF EVIDENCE: NA. Laryngoscope, 126:632-637, 2016.

Racial Disparity Among the Head and Neck Cancer Population.

Head and neck cancer is the ninth most common cancer in the USA, accounting for 3.3 % of all cancers. The incidence of head and neck cancer has plateaued recently; however, morbidity and mortality continue to remain high. Moreover, racial disparity between African-American and White patients has been studied in the head and neck community, and a vast difference still remains in mortality rate and late stage at presentation. A review of the English literature was performed using PubMed/MEDLINE for demographics, epidemiology, and studies that focused on the disparity in head and neck cancer between African-American and White patients. Age-adjusted incidence of head and neck cancer is increased in African-Americans, while the 5-year survival is decreased compared to Whites. African-American patients present with more advanced disease. When receiving similar multidisciplinary care, the overall survival was not significantly different, but racial disparity often persists in treatment regimens. Socioeconomic determinants such as insurance status play a critical role in racial disparity, along with low levels of public awareness, a lack of knowledge of specific risk factors, and a sense of mistrust that is seen in the African-American population. Disparity in the head and neck cancer community is worrisome, and although efforts have been taken to decrease the disparity, a significant difference exists. Fortunately, the disparity is reversible and can be eliminated. To do so, it is critical to extend to underserved community programs that provide appropriate screening and diagnosis, with subsequent follow-up and treatment following the standards of care.