Lenalidomide induced pneumonitis.

INTRODUCTION: Iatrogenic lung injury is a very rare, albeit serious complication with antineoplastic therapy, including immunomodulatory drugs. Pneumonitis typically presents clinically with symptoms such as cough, dyspnea, fever, and hypoxemia. Radiographic evaluation often demonstrates diffuse, patchy infiltrates and ground-glass opacities. CASE REPORT: We present a case in which therapy from an immunomodulatory drug, lenalidomide, elicited a pneumonitis in the form of a 9 cm lung mass. An exhaustive workup was completed to rule out viral, bacterial, and fungal infections as well as malignant causes. Lenalidomide-induced lung injury was suspected. MANAGEMENT AND OUTCOME: Lenalidomide was discontinued and corticosteroid therapy was initiated. This resulted in a complete clinical and radiographic resolution of symptoms. DISCUSSION: Several case reports of pneumonitis have been associated with immunomodulatory drug therapy, and while most of these exhibit diffuse ground-glass opacities radiographically, our patient presented with a 9 cm lung mass. Our findings stress the importance of a thorough medication review while ruling out other potential causes of lung injury.

L-asparaginase production in solid-state fermentation using Aspergillus niger: process modeling by artificial neural network approach.

L-asparaginase has proven itself as a potential anti-cancer drug and in the mitigation of acrylamide formation in the food industry. In the present investigation, a novel utilization of niger (Guizotia abyssinica) de-oiled cake as the sole source for the cost-effective production of L-asparaginase was evaluated and compared with different agro-substrates in solid-state fermentation. The substrate provided a favorable C/N content for the L-asparaginase production as evident from the chemical composition (CHNS analysis) of the substrate. The influential process parameters viz; autoclaving time, moisture content, temperature and pH were optimized and modeled using machine-learning based artificial neural network (ANN) and statistical-based response surface methodology (RSM). The maximum enzyme activity of 34.65 ± 2.18 IU/gds was observed at 30.3 min of autoclaving time, 62% moisture content, 30 °C temperature and 6.2 pH in 96 h. A 1.36 fold improvement in enzyme activity was observed on utilizing optimized parameters. In comparison with RSM, the ANN model showed superior prediction with a low mean squared error of 0.072, low root mean squared error of 0.268 and 0.99 value of regression coefficient. The present study demonstrates the novel utilization of inexpensive and readily available agro-industrial waste for the development of cost-effective L-asparaginase production process.

Protocol to Improve Genotyping of Non-Small-Cell Lung Cancer Diagnosed Using EBUS-TBNA.

OBJECTIVES: Targeted therapies for non-small-cell lung cancers (NSCLCs) are based on the presence of driver mutations such as epidermal growth factor receptor (EGFR) and the echinoderm microtubule-associated protein-like 4-anaplastic lymphoma kinase (EML4-ALK) translocation. Endobronchial ultrasound-guided-transbronchial needle aspiration (EBUS-TBNA) is a first-line modality for diagnosing and staging NSCLC. A quality improvement protocol maximizing tissue acquisition for molecular analysis has not been previously described. METHODS: We instituted a standardized protocol designed from a multidisciplinary meeting of the pulmonology, oncology, and pathology departments for the acquisition and on-site processing of samples obtained through EBUS-TBNA to improve the yield for genetic analysis of EGFR and ALK testing. RESULTS: Preprotocol there were 50 NSCLCs (29 adenocarcinomas) and postprotocol there were 109 NSCLCs (52 adenocarcinomas). A statistically significant increase in yield for molecular analysis was seen in both EGFR (36% preprotocol and 80% postprotocol, P < 0.01) and ALK (41% preprotocol and 80% postprotocol, P < 0.01). There was no difference in complications preprotocol and postprotocol. CONCLUSIONS: Implementation of a standardized protocol with EBUS-TBNA was associated with an increase in adequacy for molecular genetic analysis in NSCLC.

Negative Predictive Value of Granulomas on EBUS-TBNA in Suspected Extrathoracic Malignancy.

PURPOSE: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a well-established diagnostic tool for lung cancer, sarcoidosis, and suspected metastatic extrathoracic malignancy. EBUS-TBNA carries a high diagnostic yield, but its negative predictive value (NPV) requires further clarification. METHODS: We reviewed EBUS-TBNA at our cancer center from 2008 to 2015. We identified negative diagnostic samples for adenopathy suspected to represent metastatic disease from extrathoracic malignancy. RESULTS: We reviewed 529 EBUS-TBNAs. Ninety patients underwent EBUS-TBNA sampling of the hilum and/or mediastinum (121 nodes, 14 masses) for suspected extrathoracic malignancy. Thirty-seven patients had negative samples (lymph node, granulomas or non-diagnostic specimens). The overall NPV was 98 %. Granulomas (11 patients, 25 nodes) seen on histology had a 100 % NPV, including those that were FDG-PET (fluorodeoxyglucose positron emission tomography) avid (n = 14 nodes). CONCLUSION: Negative EBUS-TBNA in patients with extrathoracic malignancy and suspected secondary hilar or mediastinal metastases can infer a high NPV especially if granulomas are seen on histology. Larger prospective investigations are needed to confirm the high NPV of EBUS-TBNA with granulomas in extrathoracic malignancies.

Synergistic effects of ternary mixture formulation and process parameters optimization in a sequential approach for enhanced L-asparaginase production using agro-industrial wastes.

A novel ternary mixture of inexpensive and nutrient-rich agro-substrates comprising groundnut de-oiled cake, corn gluten meal, and soybean meal has been explored to enhance the L-asparaginase production in solid-state fermentation. To achieve the aim, a hybrid strategy was implemented by utilizing a combination of a mixture design and artificial neural networks. The study initiated with the judicious selection of the agro-substrates based on their low C/N content in comparison to the control using the CHNS elemental analysis. The mixture composition of soybean meal (49.0%), groundnut de-oiled cake (31.5%), and corn gluten meal (19.5%) were found optimum using the simplex lattice mixture design. The agro-industrial substrates mix revealed synergistic effects on the L-asparaginase production than either of the substrates alone. The maximum L-asparaginase activity of 141.45 ± 5.24 IU/gds was observed under the physical process conditions of 70% moisture content, autoclaving period of 30 min and 6.0 pH by adopting the machine learning-derived artificial neural network (ANN) methodology. The ANN modeling showed excellent prediction ability with a low mean squared error of 0.7, a low root mean squared error of 0.84, and a high value of 0.99 for regression coefficient. Moisture content (%) was assessed to be the most sensitive process parameter in the global sensitivity analysis. The net outcome from the two sequential optimization designs is the selection of the ideal mixture composition followed by the optimum physical process parameters. The application of the enzyme demonstrated significant cytotoxicity against leukemia cell line and therefore exhibited an anti-cancer effect. The present study reports a novel mixture combination and methodology that can be used to lower the cost and enhance the production of L-asparaginase using an agro-industrial substrate mixture.

Apoptosis induction in leukemic cells by L-asparaginase preparation from Bacillus indicus: bench-scale production, purification and therapeutic application.

With the emergence of multiple side effects on the usage of commercial L-asparaginase formulations, keen interest is provoked to investigate new sources of L-asparaginases that possess antileukemic properties with minimal side effects. The present study reports the cost-effective bench-scale production, homogeneity purification and apoptosis induction potential of a new L-asparaginase preparation from Bacillus indicus against human leukemia cells. The enzyme is highly specific toward the natural substrate L-asparagine. The study initiated with the enzyme production using cost-effective substrates in which a 3.28-fold enhancement of enzyme activity was achieved in comparison with an unoptimized medium using the central composite experimental design approach. The scale-up of the process in a 3.7-L batch bioreactor resulted in 16.42 ± 0.17 IU/mL of L-asparaginase activity in 24 h. The crude extracellular enzyme was purified to homogeneity using anion exchange chromatography followed by gel filtration chromatography. A single band of approximately 35 kDa molecular weight was obtained on SDS-PAGE, while native PAGE analysis confirmed it to be a tetramer of four identical subunits. The circular dichroism spectroscopic study revealed the α + ß mixed type of secondary structure with 38.7% α-helices and 27.4% ß pleated sheets. The antitumor toxicity exhibited on the MOLT-4 leukemia cells by the new L-asparaginase was revealed using the MTT assay and acridine orange/propidium iodide dual staining for live/dead cells. The flow cytometry analysis established the potential of the purified L-asparaginase to induce the apoptotic cell death mechanism in MOLT-4 leukemia cells. Conclusively, the L-asparaginase of Bacillus indicus is a highly promising candidate that can be introduced as a new enzyme therapeutic against various leukemia disorders.

Natural phytocompounds physalin D, withaferin a and withanone target L-asparaginase of Mycobacterium tuberculosis: a molecular dynamics study.

Tuberculosis is a major infectious disease that is responsible for high mortality in humans. The reason for the global burden is the emergence of new antibiotic resistant strains of Mycobacteria that showed resistance against the currently given therapy. It is identified that the pathogen utilizes the L-asparaginase enzyme as a virulence factor for survival benefits inside the host. Therefore, L-asparaginase of Mycobacterium tuberculosis is a promising therapeutic drug target. In view of the light, the present study explores thirty phytocompounds from medicinal plants to determine the binding affinity in the catalytic site of L-asparaginase. The studies initiated with the construction of the 3 D structure of L-asparaginase using homology modeling. Using the robustness of molecular docking with binding energy cut-off value < -9.0 kcal/mol and 100 ns molecular dynamics simulations, three phytocompounds viz., Physalin D (-9.11 kcal/mol), Withanone (-9.45 kcal/mol) and Withaferin A (-9. 67 kcal/mol) showed strong binding potential compared to the product, L-aspartate (-5.87 kcal/mol). The active site residues identified are Thr 12, Asp 51, Ser 53, Thr 84, Asp 85, and Lys 157. Upon MD simulations, the phytocompounds and the product L-aspartate remain present in the same catalytic pocket of the enzyme. The RMSD, RMSF, radius of gyration and H-bond analysis of enzyme ligand complexes efficiently showed the stability of ligands at the docked site. Further, ADME studies distinctly demonstrate the potential of selected phytoconstituents as therapeutics. Thus, serve as safe and low-cost alternatives to chemical compounds to be used in combination therapy for treatment of tuberculosis.Communicated by Ramaswamy H. Sarma.

Effect of Bronchoscopic Spray Cryotherapy and Ultra-low Temperature on Physical Properties of Metallic and Silicone Airway Stents.

BACKGROUND: Bronchoscopic spray cryotherapy (SCT) is utilized in the field of interventional pulmonology for treating benign and malignant airway stenosis as a standard tool to maintain airway patency. Stent-related complications include tumor overgrowth, granulation tissue, and epithelialization. Thermal ablation can have a limited role in such scenarios due to the risk of airway fire and damage to the existing stent. SCT is a potential therapy using ultra-low temperatures that can allow stents to remain in place during treatment. However, there has been no study demonstrating the safety of SCT on the integrity and physical properties of tracheobronchial stents. We report the results of the first study demonstrating the safety of SCT utilized to treat stent-associated granulation or malignant airway disease. The aim of this study was to demonstrate the effects of SCT on the physical properties of airway stents in an ex vivo environment. METHODS: Various types of airway stents were subjected to multiple intervals of SCT for up to 30 seconds, and then the cycle was repeated 3 times. After every cycle, we compressed the stents to 60% of their original size, and compression and expansion force data was collected immediately after, at 3-minute and 5-minute intervals, and compared with the baseline readings. RESULTS: There was no significant change in the association between diameter and compression/expansion force, including any derangement in returning to the original diameter or any physical damage to any of the stents even after 3 prolonged SCT sessions of 30 seconds. CONCLUSION: Our study provides the first evidence that the use of SCT in conjunction with existing silicone/metal stents is feasible and does not cause any physical damage to the stents or alters their ability to maintain the original diameter.

Lesion characteristics affecting yield of electromagnetic navigational bronchoscopy.

RATIONALE: Electromagnetic navigational bronchoscopy (ENB) is an important, minimally invasive diagnostic tool for malignant and benign peripheral lung lesions, offering lower complication risks than transthoracic needle aspirations. As a relatively new technology, the best sampling modality and lesion characteristics for ENB has yet to be determined. We evaluated the sensitivity and diagnostic yield of different sampling modalities (needle aspiration, brush biopsy, transbronchial forceps biopsies) and radiographical lesion characteristics by Tsuboi classification. We also evaluated the difference in yield and sensitivity with the addition of radial probe EBUS to augment ENB. METHODS: We completed a retrospective chart review of all patients that had ENB performed at our institution since its implementation in 2011. We reviewed the lesion size, location, Tsuboi classification, cytology, pathology results and analyzed biopsy specimen tool types. RESULTS: We included a total of 248 patients who had ENB performed between 2011 and 2018. Average age was 67 years and 50% female. A total of 270 lesions were targeted with a mean size of 24 ± 12 mm. Sensitivity for malignancy was 59.2% with a diagnostic yield of 72.3%. Sensitivity and diagnostic accuracy trended higher with combined sampling modalities (brush and transbronchial needle aspiration and forcep biopsy). Lesions with type I and type II Tsuboi classification of bronchus sign had higher sensitivity compared to type III classification (67.9% [n = 101 type I], 64.6% [n = 65 type II], 37.9% [n = 36 type III]), p = 0.01 and p = 0.04. CONCLUSION: For navigation bronchoscopy, sensitivity is higher in bronchus sign lesions that end directly into lesion (Tsuboi type I) and travel through malignant lesions (Tsuboi type II) compared to tangentially circumventing the lesion (Tsuboi type III).

A Handoffs Software Led to Fewer Errors of Omission and Better Provider Satisfaction: A Randomized Control Trial.

BACKGROUND: Computer-assisted communication is shown to prevent critical omissions ("errors") in the handoff process. OBJECTIVE: The aim of the study was to study this effect and related provider satisfaction, using a standardized software. METHODS: Fourteen internal medicine house officers staffed 6 days and 1 cross-covering teams were randomized to either the intervention group or control, employing usual handoff, so that handoff information was exchanged only between same-group subjects (daily, for 28 days). RESULTS: In the intervention group, fewer omissions (among those studied) occurred intravenous access (17 versus 422, P < 0.001), code status (1 versus 158, P < 0.001), diet/nothing per mouth (28 versus 477, P < 0.001), and deep venous thrombosis prophylaxis (17 versus 284, P < 0.001); duration to compose handoff was similar; and physicians perceived less workload adjusted for patient census and provider characteristics (P = 0.004) as well as better handoff quality (P < 0.001) and clarity (P < 0.001). CONCLUSIONS: The intervention was associated with fewer errors and superior provider satisfaction.

Synthesis, characterization and anticandidal activity of dioxomolybdenum(VI) complexes of the type [MoO2{ON=C(CH3)Ar}2] and [MoO2{OC(R)CHC(R')=NC6H5}2].

Interaction of [MoO2(acac)2] with internally functionalized oximes like HON=C(CH3)Ar (Ar = C4H3S, C4H3O or C5H4N) and Schiff's Bases derived from ß - diketones like HOC(R)CHC(R')=NC6H5 (R = R' = CH3 or C6H5; R = CH3 and R' = C6H5) led to the formation of yellow dioxomolybdenum(VI) complexes of the type [MoO2{ON=C(CH3)Ar}2] and [MoO2{OC(R)CHC(R')=NC6H5}2]. Oximes were synthesized by green methodology. The newly synthesized complexes were characterized on basis of elemental analysis and various spectral findings. Anticandidal activity of [MoO2{ON=C(CH3)C6H4N}2] clearly reveals that the complex is biologically active against fungal diseases.

Insights into the Microbial L-Asparaginases: from Production to Practical Applications.

L-asparaginase is a valuable protein therapeutic drug utilized for the treatment of leukemia and lymphomas. Administration of asparaginase leads to asparagine starvation causing inhibition of protein synthesis, growth, and proliferation of tumor cells. Besides its clinical significance, the enzyme also finds application in the food sector for mitigation of a cancer-causing agent acrylamide. The numerous applications ensue huge market demands and create a continued interest in the production of costeffective, more specific, less immunogenic and stable formulations which can cater both the clinical and food processing requirements. The current review article approaches the process parameters of submerged and solid-state fermentation strategies for the microbial production of the L-asparaginase from diverse sources, genetic engineering approaches used for the production of L-asparaginase enzyme and major applications in clinical and food sectors. The review also addresses the immunological issues associated with the L-asparaginase usage and the immobilization strategies, drug delivery systems employed to circumvent the toxicity complications are also discussed. The future prospects for microbial Lasparaginase production are discussed at the end of the review article.