Predicted 25-hydroxyvitamin D over the adult life and the risk of ovarian cancer.

The evidence from previous studies of serum 25-hydroxyvitamin D [25(OH)D] and ovarian cancer risk are not conclusive. However, 25(OH)D was generally only measured in late adulthood, which may not capture the etiologically relevant exposure periods. We investigated predicted 25(OH)D over the adult lifetime in relation to ovarian cancer risk in a population-based case-control study conducted from 2011 to 2016 in Montreal, Canada (490 cases, 896 controls). Predicted 25(OH)D was computed using previously validated regression models. Unconditional multivariable logistic regression models were used to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI) for average predicted 25(OH)D over the adult life and risk. In addition, the relative importance of different periods of past 25(OH)D exposure was explored using a weighted cumulative exposure (WCE) model. For each 20 nmol/L increase in average predicted 25(OH)D over the adult life, the aOR (95% CI) was 0.73 (0.55-0.96). In WCE analyses, the inverse association was strongest for exposures 5 to 20 years and 35 to 55 years prior to diagnosis, with aORs (95% CIs) of 0.82 (0.69-0.94) and 0.79 (0.66-1.02), respectively, for each 20 nmol/L increase in predicted 25(OH)D. These results support an inverse association between 25(OH)D in adulthood and ovarian cancer risk.

Novel Calcium Phosphate Promotes Interbody Bony Fusion in a Porcine Anterior Cervical Discectomy and Fusion Model.

STUDY DESIGN: Experimental porcine anterior cervical discectomy and fusion (ACDF) model: a proof-of-concept study. OBJECTIVE: The effect of monetite synthetic bone graft containing calcium pyrophosphate (Ca-PP) and ß-tricalcium phosphate (ß-TCP) on cervical spinal fusion in a non-instrumented two-level large animal model. SUMMARY OF BACKGROUND DATA: ACDF is the gold standard surgical technique for the treatment of degenerative cervical spinal diseases. However, pseudarthrosis associated with increased patient morbidity occurs in approximately 2,6% of the surgeries. Synthetic bone graft (SBG) may enhance bony fusion and subsequently decrease the risk of pseudarthrosis. Recent studies on monetite-based synthetic bone grafts for use in large cranial defects in humans have shown promising bone healing results, necessitating further investigation of their use in cervical spinal fusion. METHODS: Four adult female Danish Göttingen mini-pigs received partial cervical anterior discectomy and intervertebral defects at an upper and lower level. One defect was filled with SBG and the other was left empty. Bony fusion was evaluated using computed tomography (CT) at three-month intervals for 12 months. Fifteen months post-surgery, the animals were euthanized for further ex vivo qualitative histopathological and micro-CT evaluations. Fusion rates were compared using Fisher´s exact test at each time point. RESULTS: Increased interbody bony fusion rates were observed at synthetic bone graft levels (4/4) compared with control levels (0/4) evaluated by CT at 6- and 9-months post-surgery ( P = 0.029). Fusion was observed at all synthetic bone graft levels 12 months post-surgery and at only one control level. Histopathological evaluation confirmed high-quality interbody bony fusion at all synthetic bone graft levels, and fusion by spondylosis at one control level. CONCLUSION: This proof-of-concept study provides preliminary evidence of a novel, Ca-PP -and ß-TCP-containing monetite SBG that promotes bony fusion compared to a negative control in a clinically relevant porcine model of ACDF. LEVEL OF EVIDENCE: N/A.

Measuring prognostic awareness in patients with advanced cancer: a scoping review and interpretive synthesis of the impact of hope.

BACKGROUND: Assessment of prognostic awareness (PA) in patients with advanced cancer is challenging because patient responses often indicate their hopes. The objectives of this scoping review were to summarize studies that measured PA in patients with advanced cancer and to synthesize data about how PA was measured and whether hope was incorporated into the measurement. METHODS: MEDLINE and Embase databases were searched from inception to December 14, 2021. Data regarding the impact of hope on assessment of PA were extracted when studies reported on patients' beliefs about prognosis and patients' beliefs about their doctor's opinion about prognosis. An interpretive synthesis approach was used to analyze the data and to generate a theory regarding the incorporation of hope into the assessment of PA. RESULTS: In total, 52 studies representing 23 766 patients were included. Most were conducted in high-income countries and measured PA based on the goal of treatment (curable vs incurable). Five studies incorporated hope into the assessment of PA and reported that among patients who responded that their treatment goal was a cure, an average of 30% also acknowledged that their doctors were treating them with palliative intent. Interpretive synthesis of the evidence generated a trinary conceptualization of PA patients who are aware and accepting of their prognosis; aware and not accepting; and truly unaware. Each of these groups will benefit from different types of interventions to support their evolving PA. CONCLUSION: The trinary conceptualization of PA may promote understanding of the impact of hope in the assessment of PA and guide future research.

Canine ex vivo tarsal arthrodesis: fixation by using a new bone tissue glue.

Introduction: Arthrodesis, performed as a salvage surgical procedure to treat intractable joint conditions in dogs and cats, is associated with a high incidence of complications intra and postoperative, proving the need for improved and new techniques in arthrodesis surgery. Adding a new resorbable bone glue to the arthrodesis could potentially add fixation strength and lower complications. The objectives of this experimental ex vivo biomechanical study were therefore to develop a biomechanical test model of partial tarsal arthrodesis and to determine whether the new resorbable bone glue (phosphoserine modified cement) produced measurable fixation strength in canine calcaneoquartal arthrodesis, without orthopedic implants. Methods: Four biomechanical test models with a total of 35 canine tarsal joints were used. Soft tissues were dissected to 4 different test models with variable contributions from soft tissues. The calcaneoquartal joint was prepared as in vivo arthrodesis and the glue was applied to joint surfaces as a liquid/putty (0.4 cc). After curing for 24 h, a shear force was applied to the joint (1 mm per minute) and the failure strength was recorded. Results: Calcaneoquartal joints, where all soft tissues had been completely resected and fixated with glue (1-1.5 cm2 joint surface), withstood 2-5 mm of displacement and an average of 100 ± 58 N/cm2 of shear force (Model 1). Similar adhesive fixation strengths were obtained in Model 2 and 3 with increasing contributions from soft tissues (80 ± 44 and 63 ± 23 N/cm2, p = 0.39, ANOVA). Conclusion: The developed biomechanical model was sensitive enough to measure differences in fixation strengths between different glue formulations. The average fixation strength (60-100 N/cm2) should be strong enough to support short-term load bearing in medium sized canines (20 kg). The developed cadaver biomechanical test model is of potential use for other arthrodesis studies. The new resorbable glue can potentially contribute to stability at arthrodesis surgery, acting as a complement to today's standard fixation, metal implants.

The ionic and ground states of gamma-pyrone. The photoionization spectrum studied by synchrotron radiation and interpreted by configuration interaction and density functional calculations.

A synchrotron-based photoionization spectrum up to 27 eV represents a considerable improvement in resolution over early He(I) and He(II) spectra. Symmetry-adapted coupled cluster calculations of the ionic state sequence give the sequence of state vertical ionization energies (VIE) as 12B2 < 12B1 < 12A2 < 22B1 < 12A1. Generally, these symmetry-adapted cluster configuration interactions VIE match reasonably well with the experimental spectrum over this wide energy range. Density functional calculations of the corresponding adiabatic terms (AIE) were also performed. Higher energy ionic states were determined by complete active space self-consistent field methods; these include all π-ionizations and some σ-ionic states. These were analyzed by Franck-Condon (FC) procedures and compared with an experiment. The spectral onset is complex, where two states, later shown to be the 12B2 and 12B1 states, are strongly overlapping. The superposition of the FC vibrational structure in the 12B2 and 12B1 states accounts for most of the peaks arising at the onset of the photoelectron spectra. However, the small separation between these two ionic states makes vibronic interaction fairly inevitable. In the absence of Herzberg-Teller analyses for ionic states, we have sought and determined a transition state between the 12B2 and 12B1 states, showing that vibronic coupling does occur. The lack of degradation in the vibrational envelope of the higher of the two states contrasts with our previous work on the halogenobenzenes, where overlapping state envelopes led to considerable widening of the line width at half-height of the higher energy states.

The importance of appropriate processing and direct microscopic examination for the timely diagnosis and management of invasive infections caused by filamentous fungi.

The gold standard for diagnosis of invasive fungal infections caused by filamentous fungi remains the visualization of fungal elements in fluids, and biopsy/tissue collected from a normally sterile body site. Parallel recovery of viable fungus from the sample subsequently permits antifungal susceptibility testing of the individual isolate. Central to both processes is the appropriate processing of tissue specimens to avoid damaging fungal elements and optimize viable organism recovery. Historically, mycologists have proposed that homogenization (grinding or bead-beating) of tissue should be avoided in cases of suspected fungal infection as it likely damages hyphae, instead preferring to chop tissue into small portions (dicing) for direct microscopic examination and culture. Here, we have compared the two processes directly on material from clinical patient cases of mucoromycosis and invasive aspergillosis. Representative portions of fresh biopsy samples were processed in parallel either by chopping (dicing) in the mycology reference laboratory or by bead-beating in the adjoining general microbiology laboratory. Aliquots of the samples were then cultured under identical conditions and subjected to direct microscopic examination. The results demonstrated that tissue homogenization significantly reduced (i) organism recovery rates in cases of both mucoromycosis and invasive aspergillosis and (ii) the number of fungal elements detectable upon direct microscopic examination. To our knowledge, this is the first study to directly compare these alternative processing methods and despite only employing a limited number of samples the data presented here, provide support for the perceived mycological wisdom that homogenization of tissue samples should be avoided when filamentous fungal infections are suspected.

The gold standard for diagnosis of fungal infections remains the visualization of fungal elements in samples from usually sterile sites. Here we show that certain methods employed for processing biopsy samples significantly impact the ability to detect and grow fungi from genuine cases of infection.

Protein Kinase A Downregulation Delays the Development and Progression of Polycystic Kidney Disease.

BACKGROUND: Upregulation of cAMP-dependent and cAMP-independent PKA signaling is thought to promote cystogenesis in polycystic kidney disease (PKD). PKA-I regulatory subunit RIα is increased in kidneys of orthologous mouse models. Kidney-specific knockout of RIα upregulates PKA activity, induces cystic disease in wild-type mice, and aggravates it in Pkd1RC/RC mice. METHODS: PKA-I activation or inhibition was compared with EPAC activation or PKA-II inhibition using Pkd1RC/RC metanephric organ cultures. The effect of constitutive PKA (preferentially PKA-I) downregulation in vivo was ascertained by kidney-specific expression of a dominant negative RIαB allele in Pkd1RC/RC mice obtained by crossing Prkar1αR1αB/WT, Pkd1RC/RC , and Pkhd1-Cre mice (C57BL/6 background). The effect of pharmacologic PKA inhibition using a novel, selective PRKACA inhibitor (BLU2864) was tested in mIMCD3 3D cultures, metanephric organ cultures, and Pkd1RC/RC mice on a C57BL/6 × 129S6/Sv F1 background. Mice were sacrificed at 16 weeks of age. RESULTS: PKA-I activation promoted and inhibition prevented ex vivo P-Ser133 CREB expression and cystogenesis. EPAC activation or PKA-II inhibition had no or only minor effects. BLU2864 inhibited in vitro mIMCD3 cystogenesis and ex vivo P-Ser133 CREB expression and cystogenesis. Genetic downregulation of PKA activity and BLU2864 directly and/or indirectly inhibited many pro-proliferative pathways and were both protective in vivo. BLU2864 had no detectable on- or off-target adverse effects. CONCLUSIONS: PKA-I is the main PKA isozyme promoting cystogenesis. Direct PKA inhibition may be an effective strategy to treat PKD and other conditions where PKA signaling is upregulated. By acting directly on PKA, the inhibition may be more effective than or substantially increase the efficacy of treatments that only affect PKA activity by lowering cAMP.

Monocytes and pyrophosphate promote mesenchymal stem cell viability and early osteogenic differentiation.

Pyrophosphate-containing calcium phosphate implants promote osteoinduction and bone regeneration. The role of pyrophosphate for inflammatory cell-mesenchymal stem cell (MSC) cross-talk during osteogenesis is not known. In the present work, the effects of lipopolysaccharide (LPS) and pyrophosphate (PPi) on primary human monocytes and on osteogenic gene expression in human adipose-derived MSCs were evaluated in vitro, using conditioned media transfer as well as direct effect systems. Direct exposure to pyrophosphate increased nonadherent monocyte survival (by 120% without LPS and 235% with LPS) and MSC viability (LDH) (by 16-19% with and without LPS). Conditioned media from LPS-primed monocytes significantly upregulated osteogenic genes (ALP and RUNX2) and downregulated adipogenic (PPAR-γ) and chondrogenic (SOX9) genes in recipient MSCs. Moreover, the inclusion of PPi (250 µM) resulted in a 1.2- to 2-fold significant downregulation of SOX9 in the recipient MSCs, irrespective of LPS stimulation or culture media type. These results indicate that conditioned media from LPS-stimulated inflammatory monocytes potentiates the early MSCs commitment towards the osteogenic lineage and that direct pyrophosphate exposure to MSCs can promote their viability and reduce their chondrogenic gene expression. These results are the first to show that pyrophosphate can act as a survival factor for both human MSCs and primary monocytes and can influence the early MSC gene expression. Graphical abstract.

Entrapment of a Cytotoxic Drug into the Crystal Structure of Calcite for Targeted Drug Delivery.

Controlled drug release and targeted drug delivery can reduce systemic toxicity of chemotherapeutics by restricting drugs to the target organ and increasing the local concentration. As tumors and inflamed tissue are often surrounded by an acidic microenvironment, pH-responsive calcium carbonates (CaCO3) are promising vehicles for controlled drug delivery applications. The aim of this study was to evaluate the loading efficacy and release of a chemotherapeutic drug, Hydroxyurea (HU), into the crystal structure of calcite. Incorporation of HU did not alter the crystallinity, crystal size, or morphology of precipitated calcite crystals, as assessed by XRD and SEM. The amount of HU was quantified by High-Pressure Liquid Chromatography (HPLC) and showed that 6.7 ± 0.7 µg of HU could be for each milligram of calcite (0.016 mol% ± 0.002). In cell media, the optimal pH for controlled release was 5 (0.1 mg/mL released after 1 h). However, in vitro, pH below 6.5 was cytotoxic to human breast cancer cells (MCF-7). Direct contact studies, where particles were incubated with MCF-7 cells, showed that the amount of HU release from calcite was not high enough to kill the cell or arrest growth at pH 6.5. Pre-dissolved release studies, where the particles were pre-dissolved in acidic media to simulate complete drug release in vivo, pH neutralized, and exposed to the cells, showed that the amount of loaded HU reduced the survival/proliferation of MCF7. In conclusion, it is possible to integrate HU into the crystal structure of a calcite crystal and release the drug in vitro at concentrations that can slow the growth of cancer cells, without affecting calcite morphology and crystallinity. Further research is needed to investigate the in vivo behavior of the particles and whether the actual tumor pH is low enough to achieve complete drug release in vivo.

Pralsetinib for RET fusion-positive non-small-cell lung cancer (ARROW): a multi-cohort, open-label, phase 1/2 study.

BACKGROUND: Oncogenic alterations in RET have been identified in multiple tumour types, including 1-2% of non-small-cell lung cancers (NSCLCs). We aimed to assess the safety, tolerability, and antitumour activity of pralsetinib, a highly potent, oral, selective RET inhibitor, in patients with RET fusion-positive NSCLC. METHODS: ARROW is a multi-cohort, open-label, phase 1/2 study done at 71 sites (community and academic cancer centres) in 13 countries (Belgium, China, France, Germany, Hong Kong, Italy, Netherlands, Singapore, South Korea, Spain, Taiwan, the UK, and the USA). Patients aged 18 years or older with locally advanced or metastatic solid tumours, including RET fusion-positive NSCLC, and an Eastern Cooperative Oncology Group performance status of 0-2 (later limited to 0-1 in a protocol amendment) were enrolled. In phase 2, patients received 400 mg once-daily oral pralsetinib, and could continue treatment until disease progression, intolerance, withdrawal of consent, or investigator decision. Phase 2 primary endpoints were overall response rate (according to Response Evaluation Criteria in Solid Tumours version 1·1 and assessed by blinded independent central review) and safety. Tumour response was assessed in patients with RET fusion-positive NSCLC and centrally adjudicated baseline measurable disease who had received platinum-based chemotherapy or were treatment-naive because they were ineligible for standard therapy. This ongoing study is registered with ClinicalTrials.gov, NCT03037385, and enrolment of patients with treatment-naive RET fusion-positive NSCLC was ongoing at the time of this interim analysis. FINDINGS: Of 233 patients with RET fusion-positive NSCLC enrolled between March 17, 2017, and May 22, 2020 (data cutoff), 92 with previous platinum-based chemotherapy and 29 who were treatment-naive received pralsetinib before July 11, 2019 (efficacy enrolment cutoff); 87 previously treated patients and 27 treatment-naive patients had centrally adjudicated baseline measurable disease. Overall responses were recorded in 53 (61%; 95% CI 50-71) of 87 patients with previous platinum-based chemotherapy, including five (6%) patients with a complete response; and 19 (70%; 50-86) of 27 treatment-naive patients, including three (11%) with a complete response. In 233 patients with RET fusion-positive NSCLC, common grade 3 or worse treatment-related adverse events were neutropenia (43 patients [18%]), hypertension (26 [11%]), and anaemia (24 [10%]); there were no treatment-related deaths in this population. INTERPRETATION: Pralsetinib is a new, well-tolerated, promising, once-daily oral treatment option for patients with RET fusion-positive NSCLC. FUNDING: Blueprint Medicines.

Factors predicting missing instruments in three cancer randomized clinical trials.

PURPOSE: Missing patient-reported outcome (PRO) data can seriously threaten the validity of randomized clinical trials (RCTs). Identifying which factors predict missing instruments may help researchers develop strategies to prevent it from happening. This study examined the association of factors with time to the first missing instrument after randomization in three cooperative group RCTs. METHODS: We performed descriptive analyses and Cox proportional hazards regressions for three RCTs selected from the Canadian Cancer Trials Group: MA17 (breast cancer), PR7 (prostate cancer), and LY12 (non-Hodgkin's lymphoma). The outcome was the time from randomization to the first missing instrument. Variables for 15 factors were used as covariates based on availability and previously-reported putative associations with missing PRO data. RESULTS: Nine percent of 1352 subjects on MA17, 37% of 923 subjects on PR7, and 59% of 477 subjects on LY12 had a missing instrument. Twenty-five percent of subjects on MA17 had first missing instrument within 4.6 years. The median time to first missing instrument was: not observed for MA17, 7.3 years for PR7, 0.12 years for LY12. Cox regression revealed statistically significant independent associations with outcome for only five factors: baseline age (PR7) and level of well-being (LY12), and centre level of activity (LY12), presence of post-graduate residency training program (MA17, PR7), and centre geographic location (PR7, LY12). CONCLUSION: Many factors reported to have association with missing instruments do not seem to predict time to the first missing instrument after randomization in RCTs. Context is important in understanding the few that may.

In Vitro Antifungal Drug Resistance Profiles of Clinically Relevant Members of the Mucorales (Mucoromycota) Especially with the Newer Triazoles.

Mucoromycoses (infections caused by members of the order Mucorales, phylum Mucoromycota [ex-Zygomycota]) are highly destructive, rapidly progressive infections, with dire prognoses especially when they occur in immunocompromised hosts. Current treatment guidelines recommend liposomal formulations of amphotericin B with adjunctive surgery as first line therapy, with the newer triazoles posaconazole or isavuconazole as alternative treatments, or as salvage therapy. Among the many organisms belonging to this order, a limited number of species in the genera Rhizopus, Mucor, Lichtheimia and Rhizomucor are responsible for most cases of human infection. Here, we present the minimum inhibitory concentration data (MICs) for amphotericin B, posaconazole, isavuconazole, itraconazole and voriconazole with a panel of over 300 isolates of the five most common agents of human infection (Lichtheimia corymbifera, Rhizopus arrhizus, R. microsporus, Rhizomucor pusillus and Mucor spp.) determined using the CLSI broth microdilution method. In agreement with previous studies, the most active antifungal drug for all Mucorales was amphotericin B, with MICs within the range that would predict susceptibility with Aspergillus fumigatus. Conversely, MICs for voriconazole against all species tested were high, and above the range associated with clinical efficacy with A. fumigatus. Interestingly, whilst isavuconazole and posaconazole MIC distributions indicated in vitro activity against some members of the Mucorales, activity was species-dependent for both agents. These data underscore the importance of accurate identification of the causative agents of mucoromycosis, coupled with antifungal susceptibility testing of individual isolates, in determining the optimal treatment of infections caused by these aggressive opportunistic human fungal pathogens.

Clinical research associates experience with missing patient reported outcomes data in cancer randomized controlled trials.

BACKGROUND: Missing patient reported outcomes data threaten the validity of PRO-specific findings and conclusions from randomized controlled trials by introducing bias due to data missing not at random. Clinical Research Associates are a largely unexplored source for informing understanding of potential causes of missing PRO data. The purpose of this qualitative research was to describe factors that influence missing PRO data, as revealed through the lived experience of CRAs. METHODS: Maximum variation sampling was used to select CRAs having a range of experiences with missing PRO data from academic or nonacademic centers in different geographic locations of Canada. Semistructured interviews were audio-recorded, transcribed verbatim, and analyzed according to descriptive phenomenology. RESULTS: Eleven CRAs were interviewed. Analysis revealed several factors that influence missing PRO data that were organized within themes. PROs for routine clinical care compete with PROs for RCTs. Both the paper and electronic formats have benefits and drawbacks. Missing PRO data are influenced by characteristics of the instruments and of the patients. Assessment of PROs at progression of disease is particularly difficult. Deficiencies in center research infrastructure can contribute. CRAs develop relationships with patients that may help reduce missing PRO data. It is not always possible to provide sufficient time to complete the instrument. There is a need for field guidance and a motivation among CRAs to contribute their knowledge to address issues. CONCLUSION: These results enhance understanding of factors influencing missing PRO data and have important implications for designing operational solutions to improve data quality on cancer RCTs.

Aging modulated by the Drosophila insulin receptor through distinct structure-defined mechanisms.

Mutations of the Drosophila melanogaster insulin/IGF signaling system slow aging, while also affecting growth and reproduction. To understand this pleiotropy, we produced an allelic series of single codon substitutions in the Drosophila insulin receptor, InR. We generated InR substitutions using homologous recombination and related each to emerging models of receptor tyrosine kinase structure and function. Three mutations when combined as trans-heterozygotes extended lifespan while retarding growth and fecundity. These genotypes reduced insulin-stimulated Akt phosphorylation, suggesting they impede kinase catalytic domain function. Among these genotypes, longevity was negatively correlated with egg production, consistent with life-history trade-off theory. In contrast, one mutation (InR353) was located in the kinase insert domain, a poorly characterized element found in all receptor tyrosine kinases. Remarkably, wild-type heterozygotes with InR353 robustly extended lifespan without affecting growth or reproduction and retained capacity to fully phosphorylate Akt. The Drosophila insulin receptor kinase insert domain contains a previously unrecognized SH2 binding motif. We propose the kinase insert domain interacts with SH2-associated adapter proteins to affect aging through mechanisms that retain insulin sensitivity and are independent of reproduction.

Novel Antimalarial Tetrazoles and Amides Active against the Hemoglobin Degradation Pathway in Plasmodium falciparum.

Malaria control programs continue to be threatened by drug resistance. To identify new antimalarials, we conducted a phenotypic screen and identified a novel tetrazole-based series that shows fast-kill kinetics and a relatively low propensity to develop high-level resistance. Preliminary structure-activity relationships were established including identification of a subseries of related amides with antiplasmodial activity. Assaying parasites with resistance to antimalarials led us to test whether the series had a similar mechanism of action to chloroquine (CQ). Treatment of synchronized Plasmodium falciparum parasites with active analogues revealed a pattern of intracellular inhibition of hemozoin (Hz) formation reminiscent of CQ's action. Drug selections yielded only modest resistance that was associated with amplification of the multidrug resistance gene 1 (pfmdr1). Thus, we have identified a novel chemical series that targets the historically druggable heme polymerization pathway and that can form the basis of future optimization efforts to develop a new malaria treatment.

A Biomechanical Study of Pivot-Shift and Lachman Translations in Anterior Cruciate Ligament-Sectioned Knees, Anterior Cruciate Ligament-Reconstructed Knees, and Knees With Partial Anterior Cruciate Ligament Graft Slackening: Instrumented Lachman Tests Statistically Correlate and Supplement Subjective Pivot-Shift Tests.

PURPOSE: To determine the statistical and predictive correlation between instrumented Lachman and pivot-shift tests with progressive loss of anterior cruciate ligament (ACL) function. METHODS: The kinematic correlations between pivot-shift and Lachman anterior tibial translations (ATTs) in ACL-deficient and ACL-reconstructed states and in partially lax ACL grafts were determined with precise robotic testing in cadaveric knees. The Lachman test (100-N anteroposterior) and 2 pivot-shift loadings were conducted: anterior tibial loading (100 N), valgus rotation (7 Nm), and internal rotation (5 Nm and 1 Nm). The tibia was digitized to study the resulting medial, central, and lateral tibiofemoral compartment translations. In group 1 knees, 15 bone-patellar tendon-bone reconstructions were first tested, followed by ACL graft loosening with 3- and 5-mm increases in Lachman ATT. In group 2, 43 knees underwent robotic testing before and after ACL sectioning and underwent analysis of the effect of 3- and 5-mm increases in Lachman ATT and complete ACL sectioning on pivot-shift compartment translations. RESULTS: In group 1 knees, ACL graft loosening allowing a 3-mm increase in Lachman ATT resulted in increases in pivot-shift lateral compartment translation (lateral compartment ATT) of only 1.6 ± 0.3 mm and 2.2 ± 1.0 mm (internal rotation of 5 Nm and 1 Nm, respectively) that were one-half of those required for a positive pivot-shift test finding. In group 2, for a 3-mm increased Lachman test, there were no positive pivot-shift values. In both groups, a Lachman test with an increase in ATT of 3 mm or less (100 N) had a 100% predictive value for a negative pivot-shift test finding. With ACL graft loosening and a 5-mm increase in the Lachman ATT, group 1 still had no positive pivot-shift values, and in group 2, a positive pivot-shift test finding occurred in 3 of 43 knees (7%, pivot shift 1-Nm internal rotation). After ACL sectioning, a highly predictive correlation was found between abnormal increases in Lachman and pivot-shift translations (P < .001). CONCLUSIONS: ACL graft slackening and an instrumented Lachman test with an increase in ATT of 3 mm or less were 100% predictive of a negative pivot-shift subluxation finding and retained ACL stability. Further graft slackening and a 5-mm increase in the Lachman ATT produced pivot-shift lateral compartment ATT increases still less than the values in the ACL-deficient state; however, 7% of the knees (3 of 43) were converted to a positive pivot-shift test finding indicative of ACL graft failure. CLINICAL RELEVANCE: Instrumented Lachman tests provide objective data on ACL function and graft failure to supplement subjective pivot-shift tests and are highly recommended for single-center and multicenter ACL studies. In the past decade, a near majority of published ACL studies no longer reported on instrumented Lachman tests, relying solely on highly subjective pivot-shift grading by multiple examiners.

Lead Optimization of a Pyrrole-Based Dihydroorotate Dehydrogenase Inhibitor Series for the Treatment of Malaria.

Malaria puts at risk nearly half the world's population and causes high mortality in sub-Saharan Africa, while drug resistance threatens current therapies. The pyrimidine biosynthetic enzyme dihydroorotate dehydrogenase (DHODH) is a validated target for malaria treatment based on our finding that triazolopyrimidine DSM265 (1) showed efficacy in clinical studies. Herein, we describe optimization of a pyrrole-based series identified using a target-based DHODH screen. Compounds with nanomolar potency versus Plasmodium DHODH and Plasmodium parasites were identified with good pharmacological properties. X-ray studies showed that the pyrroles bind an alternative enzyme conformation from 1 leading to improved species selectivity versus mammalian enzymes and equivalent activity on Plasmodium falciparum and Plasmodium vivax DHODH. The best lead DSM502 (37) showed in vivo efficacy at similar levels of blood exposure to 1, although metabolic stability was reduced. Overall, the pyrrole-based DHODH inhibitors provide an attractive alternative scaffold for the development of new antimalarial compounds.

The Value of Progression-Free Survival as a Treatment End Point Among Patients With Advanced Cancer: A Systematic Review and Qualitative Assessment of the Literature.

Importance: It is unclear whether patients with advanced cancer value surrogate end points, particularly progression-free survival (PFS). Despite this uncertainty, surrogate end points form the basis of regulatory approval for the majority of new cancer treatments. Objective: To summarize and qualitatively assess studies evaluating whether patients with advanced cancer understand and value PFS. Evidence Review: MEDLINE, Embase, the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, and the Cumulative Index to Nursing and Allied Health Literature databases were searched from database inception to November 12, 2018. Articles eligible for inclusion investigated patient understanding, preference, or perceived value of disease progression or PFS in the setting of advanced cancer. Three authors independently reviewed and extracted data from all studies eligible for inclusion. Findings: In total, 17 studies representing 3646 patients were included. Of these studies, 15 specifically aimed to assess patients' values toward, and their willingness to trade off toxic effects for gains or losses in the end point of PFS. All studies examined used widely disparate definitions when attempting to describe the meaning of PFS to patients. Ten studies specifically presented patients with the term progression-free survival as an attribute choice. In the words used to define the attribute of PFS, 6 studies used the term survival. Five studies clarified that PFS may not translate into better overall survival, and 5 studies explained that improvements in PFS may not reflect how well the patient may feel. No study clarified that a PFS event could represent either progression or death, and no study defined for the patient what constituted progression. The studies assessed herein underrepresented ethnic and racial minorities (mean percentage of white patients, 88%; range, 77%-96%). Values and preferences may vary across cultural backgrounds given that different relative preferences were assigned to cost and efficacy outcomes in North American vs Asian studies, although only a few studies were evaluated. Conclusions and Relevance: The existing literature evaluating patients' understanding, preferences, and values toward the end point of PFS was severely limited by the heterogeneity of methods, attribute selection, and descriptions used to define PFS to patients. High-quality studies are needed that clearly define PFS for patients and that systematically document their understanding of the term. Only then can it be assessed whether PFS is an end point of value to patients with advanced cancer.

Anterior Cruciate Ligament Graft Conditioning Required to Prevent an Abnormal Lachman and Pivot Shift After ACL Reconstruction: A Robotic Study of 3 ACL Graft Constructs.

BACKGROUND: Anterior cruciate ligament (ACL) graft conditioning protocols to decrease postoperative increases in anterior tibial translation and pivot-shift instability have not been established. PURPOSE: To determine what ACL graft conditioning protocols should be performed at surgery to decrease postoperative graft elongation after ACL reconstruction. STUDY DESIGN: Controlled laboratory study. METHODS: A 6 degrees of freedom robotic simulator evaluated 3 ACL graft constructs in 7 cadaver knees for a total of 19 graft specimens. Knees were tested before and after ACL sectioning and after ACL graft conditioning protocols before reconstruction. The ACL grafts consisted of a 6-strand semitendinosus-gracilis TightRope, bone-patellar tendon-bone TightRope, and bone-patellar tendon-bone with interference screws. Two graft conditioning protocols were used: (1) graft board tensioning (20 minutes, 80 N) and (2) cyclic conditioning (5°-120° of flexion, 90-N anterior tibial load) after graft reconstruction to determine the number of cycles needed to obtain a steady state with no graft elongation. After conditioning, the grafts were cycled a second time under anterior-posterior loading (100 N, 25° of flexion) and under pivot-shift loading (100 N anterior, 5-N·m internal rotation, 7 N·m valgus) to verify that the ACL flexion-extension conditioning protocol was effective. RESULTS: Graft board tensioning did not produce a steady-state graft. Major increases in anterior tibial translation occurred in the flexion-extension graft-loading protocol at 25° of flexion (mean ± SD: semitendinosus-gracilis TightRope, 3.4 ± 1.1 mm; bone-patellar tendon-bone TightRope, 3.2 ± 1.0 mm; bone-patellar tendon-bone with interference screws, 2.4 ± 1.5 mm). The second method of graft conditioning (40 cycles, 5°-120° of flexion, 90-N anterior load) produced a stable conditioned state for all grafts, as the anterior translations of the anterior-posterior and pivot-shift cycles were statistically equivalent ( P < .05, 1-20 cycles). CONCLUSION: ACL graft board conditioning protocols are not effective, leading to deleterious ACL graft elongations after reconstruction. A secondary ACL graft conditioning protocol of 40 flexion-extension cycles under 90-N graft loading was required for a well-conditioned graft, preventing further elongation and restoring normal anterior-posterior and pivot-shift translations. CLINICAL RELEVANCE: There is a combined need for graft board tensioning and robust cyclic ACL graft loading before final graft fixation to restore knee stability.

Comparison of Decellularized Cow and Human Bone for Engineering Bone Grafts with Human Induced Pluripotent Stem Cells.

IMPACT STATEMENT: Decellularized tissue matrices are popular as scaffolding materials for tissue engineering application. However, it is unclear whether interspecies differences in tissue parameters influence the quality of tissue grafts that are engineered using human stem cells. In this study, decellularized cow and human bone scaffolds were compared for engineering bone grafts using human induced pluripotent stem cell-derived mesodermal progenitor cells and despite minor differences in architecture and mass composition, both scaffolds equally support cell viability and tissue mineralization. Decellularized cow bone scaffolds therefore represent a suitable and more affordable alternative for engineering human bone grafts for basic and applied research.