Circulating metabolome landscape in Lynch syndrome.

Circulating metabolites systemically reflect cellular processes and can modulate the tissue microenvironment in complex ways, potentially impacting cancer initiation processes. Genetic background increases cancer risk in individuals with Lynch syndrome; however, not all carriers develop cancer. Various lifestyle factors can influence Lynch syndrome cancer risk, and lifestyle choices actively shape systemic metabolism, with circulating metabolites potentially serving as the mechanical link between lifestyle and cancer risk. This study aims to characterize the circulating metabolome of Lynch syndrome carriers, shedding light on the energy metabolism status in this cancer predisposition syndrome.This study consists of a three-group cross-sectional analysis to compare the circulating metabolome of cancer-free Lynch syndrome carriers, sporadic colorectal cancer (CRC) patients, and healthy non-carrier controls. We detected elevated levels of circulating cholesterol, lipids, and lipoproteins in LS carriers. Furthermore, we unveiled that Lynch syndrome carriers and CRC patients displayed similar alterations compared to healthy non-carriers in circulating amino acid and ketone body profiles. Overall, cancer-free Lynch syndrome carriers showed a unique circulating metabolome landscape.This study provides valuable insights into the systemic metabolic landscape of Lynch syndrome individuals. The findings hint at shared metabolic patterns between cancer-free Lynch syndrome carriers and CRC patients.

PLEKHS1 drives PI3Ks and remodels pathway homeostasis in PTEN-null prostate.

The PIP3/PI3K network is a central regulator of metabolism and is frequently activated in cancer, commonly by loss of the PIP3/PI(3,4)P2 phosphatase, PTEN. Despite huge research investment, the drivers of the PI3K network in normal tissues and how they adapt to overactivation are unclear. We find that in healthy mouse prostate PI3K activity is driven by RTK/IRS signaling and constrained by pathway feedback. In the absence of PTEN, the network is dramatically remodeled. A poorly understood YXXM- and PIP3/PI(3,4)P2-binding PH domain-containing adaptor, PLEKHS1, became the dominant activator and was required to sustain PIP3, AKT phosphorylation, and growth in PTEN-null prostate. This was because PLEKHS1 evaded pathway-feedback and experienced enhanced PI3K- and Src-family kinase-dependent phosphorylation of Y258XXM, eliciting PI3K activation. hPLEKHS1 mRNA and activating Y419 phosphorylation of hSrc correlated with PI3K pathway activity in human prostate cancers. We propose that in PTEN-null cells receptor-independent, Src-dependent tyrosine phosphorylation of PLEKHS1 creates positive feedback that escapes homeostasis, drives PIP3 signaling, and supports tumor progression.

Ovarian follicle dynamics in ewes treated with intra-vaginal progesterone pessaries. 2. Factors affecting timing of estrus and reproductive outcomes following artificial insemination.

This study extends observations on the effects of intra-vaginal progesterone treatment on the relationships between the time of luteolysis, emergence of the ovulatory follicle, timing of estrus and ewe fertility. Observations were made in progesterone - treated ewes in autumn, the spring equinox and late spring (Experiment 1, Data set 1) and in progesterone - treated ewes and naturally cycling ewes in autumn and the spring equinox (Experiment 1, Data set 2). In Data set 1, the day of emergence of both the first and second ovulatory follicle was positively related to the day luteal regression within each season. In turn, the day of emergence influenced the timing of estrus by means of a season by day of luteal regression interaction (P < 0.001) indicating that the relationship was positive in autumn and the spring equinox but negative in late spring. In autumn, older ovulatory follicles were associated with an earlier onset of estrus compared with younger ovulatory follicles. In late spring, this relationship was reversed and was influenced by whether or not ewes were cycling at the time of pessary insertion. In Data set 2, the relationship between the day of follicle emergence and luteal regression was influenced by a treatment by day of regression interaction indicating the relationship was positive in treated ewes and negative in naturally cycling ewes. Timing of estrus was positively related (P < 0.001) to both the day of luteal regression and the day of follicle emergence (P < 0.05), with both relationships being stronger in naturally cycling ewes than in treated ewes. In Experiment 2, pregnancy rate following artificial insemination in autumn was highest (90.2%) when luteolysis occurred during Days 7-9 of the pessary period compared with Days 1-6 (77.8%, P = 0.16), 10 to 12 (68.8%, P < 0.05) or Days ≥13 (71.2%, P < 0.05). Timing of estrus was not affected. The mean diameter of ovulatory follicles that emerged during Days 7-9 was larger on Day 12 (5.8 ± 0.13 mm) compared with other periods (range 4.7 ± 0.05 to 5.6 ± 0.14 mm). This study provides two potential strategies to improve the success of AI programs. Firstly, appropriately timed treatment with PGF2α to control the time of emergence of ovulatory follicles and, secondly, earlier treatment with eCG to improve the development of ovulatory follicles that emerge late in the pessary period. Each is likely to be influenced by season and the cyclical status of the ewe.

Ovarian follicle dynamics in ewes treated with intra-vaginal progesterone pessaries. 1. Follicle waves and parameters of the estrous cycle.

Progesterone treatment for synchrony of estrus is standard in sheep artificial insemination (AI) programs but can be associated with poor outcomes. Potential for improvement exists through a better understanding of the interactions between follicle development, luteal regression, emergence of the ovulatory follicle and timing of estrus. These interactions were examined by comparing progesterone-treated (Day 1 = day of pessary insertion) and naturally cycling ewes (Day 1 = day after estrus) at three times of the year (Autumn, Spring equinox and late Spring). Observations were made from Day 1 until the day of ovulation. Compared with the natural cycle, progesterone treatment (300 mg intra-vaginal pessary for 14 d) reduced the number of follicle waves (2.2 ± 0.18 versus 2.8 ± 0.12; P < 0.05) and increased the length of the ovulatory wave (8.6 ± 0.45 versus 6.6 ± 0.42 d; P < 0.05). The number of follicles per wave, the inter-wave interval and ovulation rate were not affected. However, progesterone treatment induced (P < 0.05) an earlier luteolysis (9.7 ± 0.51 versus 15.4 ± 0.49 d after Day 1), an earlier emergence of the ovulatory follicle (7.5 ± 0.48 versus 11.4 ± 0.46 d after Day 1) and an earlier onset of estrus (26.1 ± 2.95 versus 53.3 ± 2.84 h after Day 14). Time of year also influenced the response to progesterone treatment. In Autumn compared with the Spring equinox and late Spring, there was a reduction (P < 0.05) in follicle wave number (2.4 ± 0.21 versus 2.5 ± 0.29 versus 3.0 ± 0.20 respectively), follicles per wave (2.6 ± 0.27 versus 3.5 ± 0.25 versus 3.2 ± 0.20 respectively), ovulation rate (1.6 ± 0.12 versus 1.9 ± 0.12 versus 2.0 ± 0.10 respectively) and the inter-wave interval was longer (5.3 ± 0.40 versus 4.0 ± 0.32 versus 3.8 ± 0.27 d respectively; P < 0.05). Time of year also influenced (P < 0.05) the time of luteolysis (earliest in late Spring), emergence of the ovulatory follicle (earliest in Autumn) and onset of estrus (earliest in Autumn). It is concluded that (1) the effects of progesterone treatment on follicle waves are relatively minor, (2) the effects of treatment on timing of luteolysis, emergence of the ovulatory follicle and onset of estrus are all significant although the effects on AI outcomes remain to be determined and (3) time of year has a minimal effect on follicle waves but a more significant effect on other parameters of the estrous cycle. A better understanding of these complexities will assist in the development of improved protocols for synchrony of estrus.

The Association between Cyclin Dependent Kinase 2 Associated Protein 1 (CDK2AP1) and Molecular Subtypes of Lethal Prostate Cancer.

Prostate cancer (PCa) is one of the most commonly diagnosed types of malignancy and is the second leading cause of cancer-related death in men in developed countries. Cyclin dependent kinase 2 associate protein 1(CDK2AP1) is an epigenetic and cell cycle regulator gene which has been downregulated in several malignancies, but its involvement in PCa has not yet been investigated in a clinical setting. We assessed the prognostic value of CDK2AP1 expression in a cohort of men diagnosed with PCa (n = 275) treated non-surgically by transurethral resection of the prostate (TURP) and studied the relationship between CDK2AP1 expression to various PCa molecular subtypes (ERG, PTEN, p53 and AR) and evaluated the association with clinical outcome. Further, we used bioinformatic tools to analyze the available TCGA PRAD transcriptomic data to explore the underlying mechanism. Our data confirmed increased expression of CDK2AP1 with higher Gleason Grade Group (GG) and metastatic PCa (p <0.0001). High CDK2AP1 expression was associated with worse overall survival (OS) (HR: 1.62, CI: 1.19−2.21, p = 0.002) and cause-specific survival (CSS) (HR: 2.012, CI 1.29−3.13, p = 0.002) using univariate analysis. When compared to each sub-molecular type. High CDK2AP1/PTEN-loss, abnormal AR or p53 expression showed even worse association to poorer OS and CCS and remained significant when adjusted for GG. Our data indicates that CDK2AP1 directly binds to p53 using the Co-Immunoprecipitation (Co-IP) technique, which was validated using molecular docking tools. This suggests that these two proteins have a significant association through several binding features and correlates with our observed clinical data. In conclusion, our results indicated that the CDK2AP1 overexpression is associate with worse OS and CSS when combined with certain PCa molecular subtypes; interaction between p53 stands out as the most prominent candidate which directly interacts with CDK2AP1.

Movement characteristics during customized exergames after total knee replacement in older adults.

Introduction: There is limited understanding of how older adults can reach kinematic goals in rehabilitation while performing exergames and conventional exercises, and how similar or different the kinematics during exergaming are when compared with conventional therapeutic exercise with similar movement. The aim of this study was to describe the movement characteristics performed during exercise in custom-designed exergames and conventional therapeutic exercises among patients who have undergone unilateral total knee replacement (TKR). In addition, the secondary aim was to assess the relation of these exercise methods, and to assess participants' perceived exertion and knee pain during exergaming and exercising. Materials and methods: Patients up to 4 months after the TKR surgery were invited in a single-visit exercise laboratory session. A 2D motion analysis and force plates were employed to evaluate movement characteristics as the volume, range, and intensity of movement performed during custom-designed knee extension-flexion and weight shifting exergames and conventional therapeutic exercises post TKR. The perceived exertion and knee pain were assessed using the Borg Rating of Perceived Exertion and Visual Analog Scale, respectively. Results: Evaluation of seven patients with TKR [age median (IQR), 65 (10) years] revealed that the volume and intensity of movement were mostly higher during exergames. Individual goniometer-measured knee range of motion were achieved either with exergames and conventional therapeutic exercises, especially in knee extension exercises. The perceived exertion and knee pain were similar after exergames and conventional therapeutic exercises. Conclusions: During custom-designed exergaming the patients with TKR achieve the movement characteristics appropriate for post-TKR rehabilitation without increasing the stress and pain experienced even though the movement characteristics might be partly different from conventional therapeutic exercises by the volume and intensity of movement. Physical therapists could consider implementing such exergames in rehabilitation practice for patients with TKR once effectiveness have been approved and they are widely available.

AIM2 Suppresses Inflammation and Epithelial Cell Proliferation during Glomerulonephritis.

Absent in melanoma-2 (AIM2) is an inflammasome-forming innate immune sensor for dsDNA but also exhibits inflammasome-independent functions such as restricting cellular proliferation. AIM2 is expressed in the kidney, but its localization and function are not fully characterized. In normal human glomeruli, AIM2 localized to podocytes. In patients with glomerulonephritis, AIM2 expression increased in CD44+-activated parietal epithelial cells within glomerular crescents. To explore AIM2 effects in glomerular disease, studies in Aim2 -/- mice were performed. Aim2-/- glomeruli showed reduced expression of Wilm tumor gene-1 (WT1), WT1-driven podocyte genes, and increased proliferation in outgrowth assays. In a nephrotoxic serum (NTS)-induced glomerulonephritis model, Aim2-/- (B6) mice exhibited more severe glomerular crescent formation, tubular injury, inflammation, and proteinuria compared with wild-type controls. Inflammasome activation markers were absent in both Aim2 -/- and wild-type kidneys, despite an increased inflammatory transcriptomic signature in Aim2 -/- mice. Aim2 -/- mice also demonstrated dysregulated cellular proliferation and an increase in CD44+ parietal epithelial cells during glomerulonephritis. The augmented inflammation and epithelial cell proliferation in Aim2 -/- (B6) mice was not due to genetic background, as Aim2 -/- (B6.129) mice demonstrated a similar phenotype during NTS glomerulonephritis. The AIM2-like receptor (ALR) locus was necessary for the inflammatory glomerulonephritis phenotype observed in Aim2 -/- mice, as NTS-treated ALR -/- mice displayed equal levels of injury as wild-type controls. Podocyte outgrowth from ALR -/- glomeruli was still increased, however, confirming that the ALR locus is dispensable for AIM2 effects on epithelial cell proliferation. These results identify a noncanonical role for AIM2 in suppressing inflammation and epithelial cell proliferation during glomerulonephritis.

Decreased ATM Protein Expression Is Substantiated with PTEN Loss in Defining Aggressive Phenotype of Prostate Cancer Associated with Lethal Disease.

BACKGROUND: Ataxia Telangiectasia Mutated (ATM) serine/threonine protein kinase is a known tumor suppressor, involved in DNA damage repair. It has prognostic and predictive therapeutic implications and is associated with aggressive prostate cancer (PCa). OBJECTIVE: To investigate the prognostic value of ATM protein expression in PCa patients and assessed the combined value of ATM, ERG, and PTEN status. DESIGN SETTING AND PARTICIPANTS: This study consisted of 303 patients with incidental, locally advanced, and castrate-resistant PCa by transurethral resection of the prostate (TURP). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: TURP samples from 303 PCa patients were assessed by immunohistochemistry (IHC for ATM, ERG, and PTEN. Individual and combined marker status were correlated with International Society of Urological Pathology Gleason grade group, overall survival (OS), and PCa-specific mortality (PCSM). RESULTS AND LIMITATIONS: Decreased ATM expression (negative/weak intensity) occurred in 164/303 (54.1%) patients, and was associated with shorter OS and higher PCSM (p = 0.015 and p = 0.001, respectively). Negative/weak ATM expression was significantly associated with PCSM with a hazard ratio of 2.09 (95% confidence interval 1.34-3.27, p = 0.001). Assessment of Combined ATM/PTEN expression showed improved prognostic power to predict OS and PCSM, independent of Gleason grade groups. CONCLUSIONS: Decreased ATM protein expression is associated with poor outcomes in advanced PCa patients. Patients with combined low ATM/PTEN negative expression are at the highest risk for reduced OS and PCSM. Assessing the combined status of ATM/PTEN by IHC in PCa patients may aid in risk stratification relative to OS and PCSM. Moreover, since ATM plays an integral role in DNA damage response pathways, future studies will enhance our understanding of how outcomes of patients with altered ATM and PTEN expression can be improved further with poly-ADP ribose polymerase inhibitors (PARPi), combinations of PARPi and androgen receptor-targeted therapies, as well as platinum-based chemotherapies. PATIENT SUMMARY: Lower ATM intensity is associated with increased cancer-specific mortality in prostate cancer patients. Patients with lower ATM and PTEN negative expression showed decreased overall survival and increased cancer mortality compared with controls.

Uncertainty Analysis in Intervention Impact on Health Inequality for Resource Allocation Decisions.

Cost-effectiveness analysis, routinely used in health care to inform funding decisions, can be extended to consider impact on health inequality. Distributional cost-effectiveness analysis (DCEA) incorporates socioeconomic differences in model parameters to capture how an intervention would affect both overall population health and differences in health between population groups. In DCEA, uncertainty analysis can consider the decision uncertainty around on both impacts (i.e., the probability that an intervention will increase overall health and the probability that it will reduce inequality). Using an illustrative example assessing smoking cessation interventions (2 active interventions and a "no-intervention" arm), we demonstrate how the uncertainty analysis could be conducted in DCEA to inform policy recommendations. We perform value of information (VOI) analysis and analysis of covariance (ANCOVA) to identify what additional evidence would add most value to the level of confidence in the DCEA results. The analyses were conducted for both national and local authority-level decisions to explore whether the conclusions about decision uncertainty based on the national-level estimates could inform local policy. For the comparisons between active interventions and "no intervention," there was no uncertainty that providing the smoking cessation intervention would increase overall health but increase inequality. However, there was uncertainty in the direction of both impacts when comparing between the 2 active interventions. VOI and ANCOVA show that uncertainty in socioeconomic differences in intervention effectiveness and uptake contributes most to the uncertainty in the DCEA results. This suggests potential value of collecting additional evidence on intervention-related inequalities for this evaluation. We also found different levels of decision uncertainty between settings, implying that different types and levels of additional evidence are required for decisions in different localities.

A cell-based bioluminescence assay reveals dose-dependent and contextual repression of AP-1-driven gene expression by BACH2.

Whereas effector CD4+ and CD8+ T cells promote immune activation and can drive clearance of infections and cancer, CD4+ regulatory T (Treg) cells suppress their function, contributing to both immune homeostasis and cancer immunosuppression. The transcription factor BACH2 functions as a pervasive regulator of T cell differentiation, promoting development of CD4+ Treg cells and suppressing the effector functions of multiple effector T cell (Teff) lineages. Here, we report the development of a stable cell-based bioluminescence assay of the transcription factor activity of BACH2. Tetracycline-inducible BACH2 expression resulted in suppression of phorbol 12-myristate 13-acetate (PMA)/ionomycin-driven activation of a luciferase reporter containing BACH2/AP-1 target sequences from the mouse Ifng + 18k enhancer. BACH2 expression repressed the luciferase signal in a dose-dependent manner but this activity was abolished at high levels of AP-1 signalling, suggesting contextual regulation of AP-1 driven gene expression by BACH2. Finally, using the reporter assay developed, we find that the histone deacetylase 3 (HDAC3)-selective inhibitor, RGFP966, inhibits BACH2-mediated repression of signal-driven luciferase expression. In addition to enabling mechanistic studies, this cell-based reporter may enable identification of small molecule agonists or antagonists of BACH2 function for drug development.

Maternal Supplementation with Dietary Betaine during Gestation to Improve Twin Lamb Survival.

Betaine increases the synthesis of creatine, an energy-rich amino acid that increases adenosine triphosphate (ATP) and has neuroprotective properties which may improve post-natal lamb survival. This study determined whether maternal betaine supplementation during gestation would improve body weight, thermoregulation, time to stand and suck, colostrum intake and survival to weaning of twin lambs. Twin-bearing Merino ewes received dietary betaine at either 0 g/day (Control, CTL), 2 g/day from ram introduction to parturition (Early betaine, EB) or 4 g/day from Day 80 of gestation to parturition (Late betaine, LB). Ewes were housed individually during parturition and measures were collected at 4, 24 and 72 h and Day 7 post-partum, and at marking (53.2 ± 0.2 days of age) and weaning (99.3 ± 0.2 days of age). The EB treatment resulted in heavier lambs at weaning compared with CTL and LB lambs (p < 0.05). Time to stand and suck from birth was longer in EB lambs (p < 0.05), whereas, the interval from birth to first suck was shorter for LB lambs (p < 0.05). Lamb survival rate was the highest for LB lambs at 72 h and Day 7 (p < 0.05), and lowest for EB lambs on Day 7 (p < 0.05). These data indicated that betaine supplementation at 4 g/day during the second half of pregnancy improved twin lamb survival to Day 7 and shortened the interval from birth to first suck; whereas feeding ewes 2 g/day of betaine for the duration of pregnancy increased twin lamb body weight at weaning, but increased both the time to attain behavioural milestones and mortalities before Day 7.

Impact of Socioeconomic Differences on Distributional Cost-effectiveness Analysis.

Public health decision makers value interventions for their effects on overall health and health inequality. Distributional cost-effectiveness analysis (DCEA) incorporates health inequality concerns into economic evaluation by accounting for how parameters, such as effectiveness, differ across population groups. A good understanding of how and when accounting for socioeconomic differences between groups affects the assessment of intervention impacts on overall health and health inequality could inform decision makers where DCEA would add most value. We interrogated 2 DCEA models of smoking and alcohol policies using first national level and then local authority level information on various socioeconomic differences in health and intervention use. Through a series of scenario analyses, we explored the impact of altering these differences on the DCEA results. When all available evidence on socioeconomic differences was incorporated, provision of a smoking cessation service was estimated to increase overall health and increase health inequality, while the screening and brief intervention for alcohol misuse was estimated to increase overall health and reduce inequality. Ignoring all or some socioeconomic differences resulted in minimal change to the estimated impact on overall health in both models; however, there were larger effects on the estimated impact on health inequality. Across the models, there were no clear patterns in how the extent and direction of socioeconomic differences in the inputs translated into the estimated impact on health inequality. Modifying use or coverage of either intervention so that each population group matched the highest level improved the impacts to a greater degree than modifying intervention effectiveness. When local level socioeconomic differences were considered, the magnitude of the impacts was altered; in some cases, the direction of impact on inequality was also altered.

An mTORC1-to-CDK1 Switch Maintains Autophagy Suppression during Mitosis.

Since nuclear envelope breakdown occurs during mitosis in metazoan cells, it has been proposed that macroautophagy must be inhibited to maintain genome integrity. However, repression of macroautophagy during mitosis remains controversial and mechanistic detail limited to the suggestion that CDK1 phosphorylates VPS34. Here, we show that initiation of macroautophagy, measured by the translocation of the ULK complex to autophagic puncta, is repressed during mitosis, even when mTORC1 is inhibited. Indeed, mTORC1 is inactive during mitosis, reflecting its failure to localize to lysosomes due to CDK1-dependent RAPTOR phosphorylation. While mTORC1 normally represses autophagy via phosphorylation of ULK1, ATG13, ATG14, and TFEB, we show that the mitotic phosphorylation of these autophagy regulators, including at known repressive sites, is dependent on CDK1 but independent of mTOR. Thus, CDK1 substitutes for inhibited mTORC1 as the master regulator of macroautophagy during mitosis, uncoupling autophagy regulation from nutrient status to ensure repression of macroautophagy during mitosis.

Cost-effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery: Learning from 15,856 patients.

BACKGROUND: Patients undergoing emergency abdominal surgery are exposed to a high risk of death. A quality improvement (QI) programme to improve the survival for these patients was evaluated in the Enhanced Peri-Operative Care for High-risk patients (EPOCH) trial. This study aims to assess its cost-effectiveness versus usual care from a UK health service perspective. METHODS: Data collected in a subsample of trial participants were employed to estimate costs and quality-adjusted life years (QALYs) for the QI programme and usual care within the 180-day trial period, with results also extrapolated to estimate lifetime costs and QALYs. Cost-effectiveness was estimated using incremental cost-effectiveness ratios (ICERs). The probability of being cost-effective was determined for different cost-effectiveness thresholds (£13,000 to £30,000 per QALY). Analyses were performed for lower-risk and higher-risk subgroups based on the number of surgical indications (single vs multiple). RESULTS: Within the trial period, QI was more costly (£467) but less effective (-0.002 QALYs). Over a lifetime, it was more costly (£1395) and more effective (0.018 QALYs), but did not appear to be cost-effective (ICER: £77,792 per QALY, higher than all cost-effectiveness thresholds; probability of being cost-effective: 28.7%-43.8% across the thresholds). For lower-risk patients, QI was more costly and less effective both within trial period and over a lifetime and it did not appear to be cost-effective. For higher-risk patients, it was more costly and more effective, and did not appear cost-effective within the trial period (ICER: £158,253 per QALY) but may be cost-effective over a lifetime (ICER: £14,293 per QALY). CONCLUSION: The QI programme does not appear cost-effective at standard cost-effectiveness thresholds. For patients with multiple surgical indications, this programme is potentially cost-effective over a lifetime, but this is highly uncertain.

Productivity losses in patients with newly diagnosed multiple myeloma following stem cell transplantation and the impact of maintenance therapy.

OBJECTIVE: This study examined productivity losses in European patients with newly diagnosed multiple myeloma (NDMM) undergoing autologous stem cell transplantation (ASCT), to better understand and model the impact of NDMM and lenalidomide maintenance therapy on productivity from a patient and societal perspective. METHODS: A cross-sectional online patient survey was conducted across the UK, Germany, France, Spain and Italy. A partitioned survival model was used to estimate productivity loss and the impact of maintenance therapy, using human capital (HC) and friction cost approaches. RESULTS: Of the 115 eligible survey respondents, 76.5% were economically active at the time of diagnosis and highlighted return to work as an important factor affecting their quality of life; only 39.1% of respondents were economically active post-ASCT. HC analyses estimated average total productivity losses per ASCT patient at EUR 290,601 over a 20-year period. Modelling the impact of maintenance therapy alone for these patients reduced average productivity losses by just over 10%. CONCLUSION: Patients with NDMM aspire to engage in productive lives post-ASCT, but most are unable to do so. Access to treatments extending remission and supporting engagement in a productive life can have a positive impact both for patients and wider society.

RNA proximity sequencing reveals the spatial organization of the transcriptome in the nucleus.

The global, three-dimensional organization of RNA molecules in the nucleus is difficult to determine using existing methods. Here we introduce Proximity RNA-seq, which identifies colocalization preferences for pairs or groups of nascent and fully transcribed RNAs in the nucleus. Proximity RNA-seq is based on massive-throughput RNA barcoding of subnuclear particles in water-in-oil emulsion droplets, followed by cDNA sequencing. Our results show RNAs of varying tissue-specificity of expression, speed of RNA polymerase elongation and extent of alternative splicing positioned at varying distances from nucleoli. The simultaneous detection of multiple RNAs in proximity to each other distinguishes RNA-dense from sparse compartments. Application of Proximity RNA-seq will facilitate study of the spatial organization of transcripts in the nucleus, including non-coding RNAs, and its functional relevance.

Adjunctive colposcopy technologies for assessing suspected cervical abnormalities: systematic reviews and economic evaluation.

BACKGROUND: Dynamic Spectral Imaging System (DySIS)map (DySIS Medical Ltd, Edinburgh, UK) and ZedScan (Zilico Limited, Manchester, UK) can be used adjunctively with conventional colposcopy, which may improve the detection of cervical intraepithelial neoplasia (CIN) and cancer. OBJECTIVES: To systematically review the evidence on the diagnostic accuracy, clinical effectiveness and implementation of DySISmap and ZedScan as adjuncts to standard colposcopy, and to develop a cost-effectiveness model. METHODS: Four parallel systematic reviews were performed on diagnostic accuracy, clinical effectiveness issues, implementation and economic analyses. In January 2017 we searched databases (including MEDLINE and EMBASE) for studies in which DySISmap or ZedScan was used adjunctively with standard colposcopy to detect CIN or cancer in women referred to colposcopy. Risk of bias was assessed with the Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 tool. Summary estimates of diagnostic accuracy were calculated using bivariate and other regression models when appropriate. Other outcomes were synthesised narratively. A patient-level state-transition model was developed to evaluate the cost-effectiveness of DySISmap and ZedScan under either human papillomavirus (HPV) triage or the HPV primary screening algorithm. The model included two types of clinics ['see and treat' and 'watchful waiting' (i.e. treat later after confirmatory biopsy)], as well as the reason for referral (low-grade or high-grade cytological smear). Sensitivity and scenario analyses were undertaken. RESULTS: Eleven studies were included in the diagnostic review (nine of DySISmap and two of ZedScan), three were included in the clinical effectiveness review (two of DySISmap and one of ZedScan) and five were included in the implementation review (four of DySISmap and one of ZedScan). Adjunctive DySISmap use was found to have a higher sensitivity for detecting CIN grade 2+ (CIN 2+) lesions [81.25%, 95% confidence interval (CI) 72.2% to 87.9%] than standard colposcopy alone (57.91%, 95% CI 47.2% to 67.9%), but with a lower specificity (70.40%, 95% CI 59.4% to 79.5%) than colposcopy (87.41%, 95% CI 81.7% to 91.5%). (Confidential information has been removed.) The base-case cost-effectiveness results showed that adjunctive DySISmap routinely dominated standard colposcopy (it was less costly and more effective). The only exception was for high-grade referrals in a watchful-waiting clinic setting. The incremental cost-effectiveness ratio for ZedScan varied between £272 and £4922 per quality-adjusted life-year. ZedScan also dominated colposcopy alone for high-grade referrals in see-and-treat clinics. These findings appeared to be robust to a wide range of sensitivity and scenario analyses. LIMITATIONS: All but one study was rated as being at a high risk of bias. There was no evidence directly comparing ZedScan with standard colposcopy. No studies directly compared DySIS and ZedScan. CONCLUSIONS: The use of adjunctive DySIS increases the sensitivity for detecting CIN 2+, so it increases the number of high-grade CIN cases that are detected. However, it also reduces specificity, so that more women with no or low-grade CIN will be incorrectly judged as possibly having high-grade CIN. The evidence for ZedScan was limited, but it appears to increase sensitivity and decrease specificity compared with colposcopy alone. The cost-effectiveness of both adjunctive technologies compared with standard colposcopy, under both the HPV triage and primary screening algorithms, appears to be favourable when compared with the conventional thresholds used to determine value in the NHS. FUTURE WORK: More diagnostic accuracy studies of ZedScan are needed, as are studies assessing the diagnostic accuracy for women referred to colposcopy as part of the HPV primary screening programme. STUDY REGISTRATION: This study is registered as PROSPERO CRD42017054515. FUNDING: The National Institute for Health Research Health Technology Assessment programme.

Establishing the Value of Diagnostic and Prognostic Tests in Health Technology Assessment.

In recent years, Health Technology Assessment (HTA) processes specific to diagnostics and prognostic tests have been created in response to the increased pressure on health systems to decide not only which tests should be used in practice but also the best way to proceed, clinically, from the information they provide. These technologies differ in the way value is accrued to the population of users, depending critically on the value of downstream health care choices. This paper defines an analytical framework for establishing the value of diagnostic and prognostic tests for HTA in a way that is consistent with methods used for the evaluation of other health care technologies. It assumes a linked-evidence approach where modeling is required, and incorporates considerations regarding several different areas of policy, such as personalized medicine. We initially focus on diagnostic technologies with dichotomous results, and then extend the framework by considering diagnostic tests that provide more complex information, such as continuous measures (for example, blood glucose measurements) or multiple categories (such as tumor classification systems). We also consider how the methods of assessment differ for prognostic information or for diagnostics without a reference standard. Throughout, we propose innovative graphical ways of summarizing the results of such complex assessments of value.