Rates of diabetic retinopathy among cluster analysis-identified type 2 diabetic mellitus subgroups.

PURPOSE: To determine whether phenotypic clustering of patients with diabetes mellitus (DM) is associated with more advanced diabetic retinopathy (DR). METHODS: Retrospective cohort study of 495 patients with no prior DR treatment seen at a tertiary care clinic 2014-2020. Four previously identified clusters from Ahlqvist's 2018 paper were reproduced utilizing baseline hemoglobin A1c, body mass index, and age at DM diagnosis. Age-adjusted Cox proportional hazard ratios were used to compare clusters with reference as the lowest risk cluster. RESULTS: All four type 2 DM clusters were replicated with our cohort. There was a significant difference in racial distribution among clusters (p = 0.018) with severe insulin-resistant diabetes (SIRD) having the higher percentage of Caucasians and lower percentage of Hispanics compared to other groups and a higher percentage of African Americans comprising the severe insulin-deficient diabetes (SIDD) cluster than other groups. Rates of proliferative diabetic retinopathy were higher in mild obesity-related diabetes (MOD) (28%), SIDD (24%), mild age-related diabetes (MARD) (20%), and lowest in SIRD (7.9%), overall p = 0.004. Rates of vitreous hemorrhage were higher in MOD (p = 0.032) and MARD (0.005) compared to SIRD. CONCLUSION: Baseline clinical measures may be useful in risk stratifying patients for progression to retinopathy requiring intervention.

Artificial Intelligence-Driven Morphology-Based Enrichment of Malignant Cells from Body Fluid.

Cell morphology is a fundamental feature used to evaluate patient specimens in pathologic analysis. However, traditional cytopathology analysis of patient effusion samples is limited by low tumor cell abundance coupled with the high background of nonmalignant cells, restricting the ability of downstream molecular and functional analyses to identify actionable therapeutic targets. We applied the Deepcell platform that combines microfluidic sorting, brightfield imaging, and real-time deep learning interpretations based on multidimensional morphology to enrich carcinoma cells from malignant effusions without cell staining or labels. Carcinoma cell enrichment was validated with whole genome sequencing and targeted mutation analysis, which showed a higher sensitivity for detection of tumor fractions and critical somatic variant mutations that were initially at low levels or undetectable in presort patient samples. Our study demonstrates the feasibility and added value of supplementing traditional morphology-based cytology with deep learning, multidimensional morphology analysis, and microfluidic sorting.

Electronic Health Record Usage Patterns: Assessing Telemedicine's Impact on the Provider Experience During the COVID-19 Pandemic.

Telemedicine has been widely implemented during the coronavirus disease 2019 (COVID-19) pandemic; however, its impact on those providing care remains largely understudied. Provider documentation data collected by the electronic health record (EHR) represents an underutilized tool for assessing the provider experience. Through Epic Signal, we collected data regarding the actions logged in the EHR by health care providers of the Montefiore Health System (Bronx, NY) before and after the implementation of telemedicine during the pandemic. Focusing on five metrics (appointments per day, visits closed same day, time spent outside 7 AM-7 PM, time spent on unscheduled days, and pajama time), we performed a preliminary analysis of providers across the institution, by specialty, and according to demographic characteristics such as gender and years since graduation. We observed that after telemedicine implementation, a greater proportion of providers had fewer appointments per day, closed more notes same day, and spent less time in the EHR outside of normal working hours for each of the time-related metrics. We additionally found that providers who graduated longer ago as well as female providers spent more time documenting in the EHR after hours. This brief analysis highlights the potential of using EHR data to inform decisions based on provider well-being, specifically in the setting of telemedicine implementation.

Metabolism in pluripotency: Both driver and passenger?

Pluripotent stem cells (PSCs) are highly proliferative cells characterized by robust metabolic demands to power rapid division. For many years considered a passive component or "passenger" of cell-fate determination, cell metabolism is now starting to take center stage as a driver of cell fate outcomes. This review provides an update and analysis of our current understanding of PSC metabolism and its role in self-renewal, differentiation, and somatic cell reprogramming to pluripotency. Moreover, we present evidence on the active roles metabolism plays in shaping the epigenome to influence patterns of gene expression that may model key features of early embryonic development.

Variation in target and distractor heterogeneity impacts performance in the centroid task.

In a selective centroid task, the participant views a brief cloud of items of different types-some of which are targets, the others distractors-and strives to mouse-click the centroid of the target items, ignoring the distractors. Advantages of the centroid task are that multiple target types can appear in the same display and that influence functions, which estimate the weight of each stimulus type in the cloud on the perceived centroid for each participant, can be obtained easily and efficiently. Here we document the strong, negative impact on performance that results when the participant is instructed to attend to target dots that consist of two or more levels of a single feature dimension, even when those levels differ categorically from those of the distractor dots. The results also show a smaller, but still observable decrement in performance that results when there is heterogeneity in the distractor dots.

The safety of intracytoplasmic sperm injection and long-term outcomes.

The pioneering of intracytoplasmic sperm injection (ICSI) approximately 25 years ago revolutionized the treatment of infertile couples. Today, ICSI remains an indispensable part of assisted reproductive treatments (ART) and has resulted in the birth of millions of babies. The 25th anniversary of ICSI marks a chronologic landmark in its evolving history. This landmark also serves as an opportunity to thoroughly appraise the safety of ICSI and analyze the long-term outcomes of ICSI-conceived children. In this review, we collate and analyze salient data accrued over the past 25 years pertaining to the long-term safety of ICSI and ICSI conceptions. We also evaluate the effects of ICSI on the perinatal outcomes, congenital malformation rates, cognitive development and reproductive health of ICSI-conceived neonates, children, adolescents and adults, respectively. In doing so, we also highlight the existence of potential confounders and biases that frequently obscure the interpretation of clinical follow-up studies.

Metal-binding hydrazone photoswitches for visible light reactivity and variable relaxation kinetics.

The range of applications for photoswitching moieties is diverse, and the ability to design switches with variable photochemical and physical properties is consequently important for realizing their potential. Previously we reported on the photochromism of (E)-N'-(1-(2-hydroxyphenyl)ethylidene)isonicotinohydrazide (HAPI), an aroylhydrazone compound first developed as a transition metal chelator. Herein we report the synthesis of structurally related aroylhydrazone chelators and explore the effect of these modifications on their UVA, UVC and blue light photoreactivity, photostationary state composition, photoisomer thermal stability, and relative iron(iii) binding affinity. These findings will inform the next generation of aroylhydrazone photoswitches for metal-gated photoswitching applications.

Healthcare Resource Utilization and Costs in an At-Risk Population With Diabetic Retinopathy.

Purpose: Several investigators have suggested the cost-effectiveness of earlier screening, management of risk factors, and early treatment for diabetic retinopathy (DR). We aimed to evaluate the extent of health care utilization and cost of delayed care by insurance type in a vulnerable patient population. Methods: A retrospective analysis of patients with DR was conducted using electronic medical record (EMR) data from January 2014 to December 2020 at Denver Health Medical Center, a safety net institution. Patients were classified by disease severity and insurance status. DR-specific costs were assessed via Current Procedural Terminology (CPT) codes over a 24-month follow-up period. Results: Among the 313 patients, a higher proportion of non-English speaking patients were uninsured. Rates of proliferative DR at presentation differed across insurance groups (62% of uninsured, 42% of discount plan, and 33% of Medicare/Medicaid, P = 0.016). There was a significant difference in the total median cost between discount plan patients ($1258, interquartile range [IQR] = $0 - $5901) and both Medicare patients ($751, IQR = $0, $7148, P = 0.037) and Medicaid patients ($593, IQR = $0 - $6299, P = 0.025). Conclusions: There were higher rates of proliferative DR at presentation among the uninsured and discount plan patients and greater total median cost in discount plan patients compared to Medicare or Medicaid. These findings prioritize mitigating gaps in insurance coverage and barriers to preventative care among vulnerable populations. Translational Relevance: Advanced diabetic disease and increased downstream health care utilization and cost vary across insurance type, suggesting improved access to preventative care is needed in these specific at-risk populations.

Molecular Glue Discovery: Current and Future Approaches.

The intracellular interactions of biomolecules can be maneuvered to redirect signaling, reprogram the cell cycle, or decrease infectivity using only a few dozen atoms. Such "molecular glues," which can drive both novel and known interactions between protein partners, represent an enticing therapeutic strategy. Here, we review the methods and approaches that have led to the identification of small-molecule molecular glues. We first classify current FDA-approved molecular glues to facilitate the selection of discovery methods. We then survey two broad discovery method strategies, where we highlight the importance of factors such as experimental conditions, software packages, and genetic tools for success. We hope that this curation of methodologies for directed discovery will inspire diverse research efforts targeting a multitude of human diseases.

Risk Factors and Outcomes of Delayed Presentation of Diabetic Retinopathy Patients to a County Hospital.

Purpose: To identify risk factors and evaluate outcomes of patients with delayed presentation and advanced diabetic retinopathy in our safety-net county hospital population. Methods: A retrospective study was performed on 562 patients who presented with a new diagnosis of diabetic retinopathy (DR). Delayed presentation was defined as moderate or severe nonproliferative diabetic retinopathy (NPDR) or proliferative diabetic retinopathy (PDR) at the initial visit. Comparisons between patient groups were performed with chi-square or Fisher's exact test for categorical variables and multinomial logistic regression for multivariable analysis. Linear and logistic regression modeling with general estimating equations to account for patients having two eyes was used to compare eye-level outcomes. Results: Lack of a primary care provider (PCP) was highest in patients who presented initially with PDR (28.8%), compared to 14.3% in moderate/severe NPDR, 12.4% in mild NPDR, and 7.6% in no DR groups (P < 0.001). Only 69.4% of patients with a PCP had an ophthalmology screening referral. Highest lack of referral (47.2%) was seen in the PDR group (P = 0.002). Patients with PDR were more likely to be uninsured (19.2%) compared to no and mild DR groups, with rates of 7.6% and 9.0%, respectively (P = 0.001). The PDR group had worse initial and final visual acuities (P < 0.001). Conclusions: Several risk factors were noted for delayed DR presentation, including lack of PCP, lack of screening referral, and uninsured/underinsured status. Patients with advanced DR at presentation had worse final visual outcomes despite aggressive treatment. Translational Relevance: Screening programs targeting populations with identified risk factors are essential for improving outcomes.

Vacuum-Assisted Closure Treats Refractory Esophageal Leak in a Pediatric Patient.

Esophageal perforations can have iatrogenic and non-iatrogenic causes. Early identification is a predictor of good outcomes. When identified, perforations can be managed conservatively with wide drainage or repaired surgically. Endoscopic esophageal vacuum-assisted closure may be used as a definitive treatment, particularly in scenarios where conservative management and primary surgical repair fail to achieve complete healing. We present such a scenario advocating for the consideration of endoscopic esophageal vacuum-assisted closure in patients with refractory esophageal leaks.

COSMOS: a platform for real-time morphology-based, label-free cell sorting using deep learning.

Cells are the singular building blocks of life, and a comprehensive understanding of morphology, among other properties, is crucial to the assessment of underlying heterogeneity. We developed Computational Sorting and Mapping of Single Cells (COSMOS), a platform based on Artificial Intelligence (AI) and microfluidics to characterize and sort single cells based on real-time deep learning interpretation of high-resolution brightfield images. Supervised deep learning models were applied to characterize and sort cell lines and dissociated primary tissue based on high-dimensional embedding vectors of morphology without the need for biomarker labels and stains/dyes. We demonstrate COSMOS capabilities with multiple human cell lines and tissue samples. These early results suggest that our neural networks embedding space can capture and recapitulate deep visual characteristics and can be used to efficiently purify unlabeled viable cells with desired morphological traits. Our approach resolves a technical gap in the ability to perform real-time deep learning assessment and sorting of cells based on high-resolution brightfield images.

Protocol for germ lineage differentiation of primed human pluripotent stem cells using chemically defined, nutrient-balanced media.

Metabolism regulates cell fates during early mammalian cell differentiation. This protocol describes the steps for directed differentiation of primed human pluripotent stem cells (hPSCs) into the three primary germ lineages-ectoderm, endoderm, and mesoderm-using a chemically defined nutrient-balanced media formulation. Although the transient removal and addition of specific nutrients does not occur in vivo during embryonic development, manipulation of nutrients in vitro provides an accessible method for evaluating how extracellular and intracellular metabolites help determine hPSC fate. For complete details on the use and execution of this protocol, please refer to Lu et al. (2019) and Lu et al. (2022).

Glutamine-dependent signaling controls pluripotent stem cell fate.

Human pluripotent stem cells (hPSCs) can self-renew indefinitely or can be induced to differentiate. We previously showed that exogenous glutamine (Gln) withdrawal biased hPSC differentiation toward ectoderm and away from mesoderm. We revealed that, although all three germ lineages are capable of de novo Gln synthesis, only ectoderm generates sufficient Gln to sustain cell viability and differentiation, and this finding clarifies lineage fate restrictions under Gln withdrawal. Furthermore, we found that Gln acts as a signaling molecule for ectoderm that supersedes lineage-specifying cytokine induction. In contrast, Gln in mesoderm and endoderm is the preferred precursor of α-ketoglutarate without a direct signaling role. Our work raises a question about whether the nutrient environment functions directly in cell differentiation during development. Interestingly, transcriptome analysis of a gastrulation-stage human embryo shows that unique Gln enzyme-encoding gene expression patterns may also distinguish germ lineages in vivo. Together, our study suggests that intracellular Gln may help coordinate differentiation of the three germ layers.

Chronic kidney damage pathology score for systematic assessment of the non-neoplastic kidney tissue and prediction of post-operative renal function outcomes.

To establish a systematic histological assessment of non-neoplastic kidney (NNK) tissue at the time of nephrectomy to evaluate a patient's risk of developing post-operative renal dysfunction, a combined prospective pathologic assessment of the NNK and a retrospective clinical chart review was conducted. A blinded nephropathologist performed standardized assessment of glomerular sclerosis, tubulointerstitial fibrosis, arteriosclerosis, and hyaline arteriolosclerosis. Combined these formulated the chronic kidney damage pathology score (CKDPS). Multivariate logistic regression models were developed to assess the effect of CKDPS and other clinical factors on renal function up to 24 months following nephrectomy (partial or radical). 156 patients were included in the analysis with a median age of 60 years. 70% patients underwent radical nephrectomy. A history of hypertension and/or diabetes was present in 55.8% and 22.1%, respectively. Higher CKDPS (particularly glomerular global sclerosis and arteriosclerosis scores), radical nephrectomy, and reduced baseline estimated glomerular filtration rate (eGFR) were associated with worsening post-operative renal function outcomes. The systematic assessment of non-neoplastic kidney tissue at the time of renal surgery can help identify patients at risk of post-operative renal dysfunction. CKDPS represents a standardized and prognostically relevant histologic reporting system for non-neoplastic kidney tissue.

Physician Electronic Health Record Usage as Affected by the COVID-19 Pandemic.

OBJECTIVES: To utilize metrics from physician action logs to analyze volume, physician efficiency and burden as impacted by telemedicine implementation during the COVID-19 (coronavirus disease 2019) pandemic, and physician characteristics such as gender, years since graduation, and specialty category. METHODS: We selected 11 metrics from Epic Signal, a functionality of the Epic electronic health record (EHR). Metrics measuring time spent in the EHR outside working hours were used as a correlate for burden. We performed an analysis of these metrics among active physicians at our institution across three time periods-prepandemic and telehealth implementation (August 2019), postimplementation of telehealth (May 2020), and follow-up (July 2020)-and correlated them with physician characteristics. RESULTS: Analysis of 495 physicians showed that after the start of the pandemic, physicians overall had fewer appointments per day, higher same day visit closure rates, and spent less time writing notes in the EHR outside 7 a.m. to 7 p.m. on patient scheduled days. Across all three time periods, male physicians had better EHR-defined "efficiency" measures and spent less time in the EHR outside working hours. Years since graduation only had modest associations with higher same day visit closure rates and appointments per day in May 2020. Specialty category was significantly associated with appointments per day and same day closure visit rates and also was a significant factor in the observed changes seen across the three time periods. CONCLUSION: Utilizing EHR-generated reports may provide a scalable and nonintrusive way to monitor trends in physician usage and experience to help guide health systems in increasing productivity and reducing burnout.

Noninvasive detection of fetal trisomy 21 by sequencing of DNA in maternal blood: a study in a clinical setting.

OBJECTIVE: We sought to evaluate a multiplexed massively parallel shotgun sequencing assay for noninvasive trisomy 21 detection using circulating cell-free fetal DNA. STUDY DESIGN: Sample multiplexing and cost-optimized reagents were evaluated as improvements to a noninvasive fetal trisomy 21 detection assay. A total of 480 plasma samples from high-risk pregnant women were employed. RESULTS: In all, 480 prospectively collected samples were obtained from our third-party storage site; 13 of these were removed due to insufficient quantity or quality. Eighteen samples failed prespecified assay quality control parameters. In all, 449 samples remained: 39 trisomy 21 samples were correctly classified; 1 sample was misclassified as trisomy 21. The overall classification showed 100% sensitivity (95% confidence interval, 89-100%) and 99.7% specificity (95% confidence interval, 98.5-99.9%). CONCLUSION: Extending the scope of previous reports, this study demonstrates that plasma DNA sequencing is a viable method for noninvasive detection of fetal trisomy 21 and warrants clinical validation in a larger multicenter study.