Dendritic cell vaccination combined with irreversible electroporation for treating pancreatic cancer-a narrative review.

Background and Objective: Pancreatic ductal adenocarcinoma (PDAC) is 3rd most lethal cancer in the USA leading to a median survival of six months and less than 5% 5-year overall survival (OS). As the only potentially curative treatment, surgical resection is not suitable for up to 90% of the patients with PDAC due to late diagnosis. Highly fibrotic PDAC with an immunosuppressive tumor microenvironment restricts cytotoxic T lymphocyte (CTL) infiltration and functions causing limited success with systemic therapies like dendritic cell (DC)-based immunotherapy. In this study, we investigated the potential benefits of irreversible electroporation (IRE) ablation therapy in combination with DC vaccine therapy against PDAC. Methods: We performed a literature search to identify studies focused on DC vaccine therapy and IRE ablation to boost therapeutic response against PDAC indexed in PubMed, Web of Science, and Scopus until February 20th, 2023. Key Content and Findings: IRE ablation destructs tumor structure while preserving extracellular matrix and blood vessels facilitating local inflammation. The studies demonstrated IRE ablation reduces tumor fibrosis and promotes CTL tumor infiltration to PDAC tumors in addition to boosting immune response in rodent models. The administration of the DC vaccine following IRE ablation synergistically enhances therapeutic response and extends OS rates compared to the use of DC vaccination or IRE alone. Moreover, the implementation of data-driven approaches further allows dynamic and longitudinal monitoring of therapeutic response and OS following IRE plus DC vaccine immunoablation. Conclusions: The combination of IRE ablation and DC vaccine immunotherapy is a potent strategy to enhance the therapeutic outcomes in patients with PDAC.

Irreversible electroporation of localised prostate cancer downregulates immune suppression and induces systemic anti-tumour T-cell activation - IRE-IMMUNO study.

OBJECTIVES: To prospectively compare systemic anti-tumour immune responses induced by irreversible electroporation (IRE) and robot-assisted radical prostatectomy (RARP) in patients with localised intermediate-risk prostate cancer (PCa). PATIENTS AND METHODS: Between February 2021 and June 2022, before and after treatment (at 5, 14 and 30 days) peripheral blood samples of 30 patients with localised PCa were prospectively collected. Patient inclusion criteria were: International Society of Urological Pathologists Grade 2-3, clinical cancer stage ≤T2c, prostate-specific antigen level <20 ng/mL). Patients were treated with IRE (n = 20) or RARP (n = 10). Frequency and activation status of lymphocytic and myeloid immune cell subsets were determined using flow cytometry. PCa-specific T-cell responses to prostatic acid phosphatase (PSAP) and cancer testis antigen (New York oesophageal squamous cell carcinoma 1 [NY-ESO-1]) were determined by interferon-γ enzyme-linked immunospot assay (ELISpot). Repeated-measures analysis of variance and two-sided Student's t-tests were used to compare immune responses over time and between treatment cohorts. RESULTS: Patient and tumour characteristics were similar between the cohorts except for age (median 68 years [IRE] and 62 years [RARP], P = 0.01). IRE induced depletion of systemic regulatory T cells (P = 0.0001) and a simultaneous increase in activated cytotoxic T-lymphocyte antigen 4 (CTLA-4)+ cluster of differentiation (CD)4+ (P < 0.001) and CD8+ (P = 0.032) T cells, consistent with reduction of systemic immune suppression allowing for effector T-cell activation, peaking 14 days after IRE. Effects were positively correlated with tumour volume/ablation size. Accordingly, IRE induced expansion of PSAP and/or NY-ESO-1 specific T-cell responses in four of the eight immune competent patients. Temporarily increased activated myeloid derived suppressor cell frequencies (P = 0.047) were consistent with transient immunosuppression after RARP. CONCLUSIONS: Irreversible electroporation induces a PCa-specific systemic immune response in patients with localised PCa, aiding conversion of the tumour microenvironment into a more immune permissive state. Therapeutic efficacy might be further enhanced by combination with CTLA-4 checkpoint inhibition, potentially opening up a new synergistic treatment paradigm for high-risk localised or (oligo)metastatic disease.

Predictors of prolonged supratherapeutic serum lithium concentrations: a retrospective chart review.

INTRODUCTION: The Extracorporeal Treatments in Poisoning (EXTRIP) workgroup suggests hemodialysis in severe lithium poisoning if specific criteria are met. One criterion is if the expected time to obtain a lithium concentration <1.0 mEq/L with optimal management is >36 h. There are a lack of data regarding which patient characteristics are associated with the rate at which patients achieve a lithium concentration <1.0 mEq/L. METHODS: We conducted a retrospective chart review analyzing hospital electronic medical records. Inclusion criteria consisted of a lithium concentration >1.2 mEq/L during hospitalization. We excluded patients who received extracorporeal treatment before 36 h elapsed from time of initial lithium concentration >1.2 mEq/L. The primary analysis consisted of a Cox regression and a secondary analysis evaluated the nomogram method described by Buckley and colleagues for predicting prolonged supratherapeutic lithium concentration. RESULTS: One hundred and one patients were included in the study. The median time to reach a lithium concentration <1.0 mEq/L was 42.5 h (IQR: 33.8-51.1). Older patients, patients taking a thiazide, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, patients with a higher initial lithium concentration, and patients with higher sodium concentrations achieved a lithium concentration <1 mEq/L at a slower rate. For the nomogram analysis, sensitivity (61.5%) and specificity (54.5%) were moderate, the positive predictive value (16.7%) was poor, and the negative predictive value (90.6%) was excellent. DISCUSSION: The results from our primary analysis suggest that identifying higher serum sodium concentration and use of certain antihypertensives that decrease glomerular filtration rate as predictors of an increased time to reach a therapeutic lithium concentration may help identify patients who meet the Extracorporeal Treatments in Poisoning criteria for hemodialysis. The nomogram method performed similarly to prior validation studies. CONCLUSIONS: In this retrospective chart review of patients with supratherapeutic lithium concentrations, we identified several risk factors for prolonged supratherapeutic lithium concentrations.

Significant hemolysis is present during irreversible electroporation of cardiomyocytes in vitro.

BACKGROUND: Pulsed-field ablation (PFA) of atrial fibrillation (AF) is a new method in clinical practice. Despite a favorable safety profile of PFA in AF ablation, rare cases of renal failure, probably due to hemolysis, have been recently reported. OBJECTIVE: The aim of this study was to determine the rate of hemolysis and cardiac cell death during in vitro PFA with different electric field intensities. METHODS: Blood samples from healthy volunteers and mouse HL-1 cardiomyocyte cell lines were subjected to in vitro irreversible electroporation (IRE) using 216 bipolar pulses, each lasting 2 µs with 5 µs intervals, repeated 20 times at a frequency of 1 Hz. These pulses varied in from 500 to 1500 V. Cell-free hemoglobin levels were assessed spectrophotometrically, and red blood cell microparticles (RBCµ) were evaluated using flow cytometry. Cardiomyocyte death was quantified using propidium iodide. RESULTS: PF energy (1000 V/cm, 1250 V/cm, and 1500 V/cm) was associated with a significant increase in cell-free hemoglobin (0.31 ± 0.16 g/l, 2.33 ± 0.90 g/l, and 5.7 ± 0.20 g/l, p< 0.05), and similar increase in the concentration of RBCµ. Significant rates of cardiomyocyte death were observed at electric field strengths of 750 V/cm, 1000 V/cm, 1250 V/cm and 1500 V/cm (26.5 ± 5.9%, 44.3 ± 6.2%, 55.5 ± 6.9% and 74.5 ± 17.8% of cardiomyocytes, p < 0.05). CONCLUSION: The most effective induction of cell death in vitro was observed at 1500 V/cm. This intensity was also associated with a significant degree of hemolysis.

Application Repetition and Electrode-Tissue-Contact Results in Deeper Lesions Using a Pulsed-Field Ablation Circular Variable Loop Catheter.

BACKGROUND: Pulsed field ablation (PFA) is a novel, myocardial-selective, non-thermal ablation modality used to target cardiac arrhythmias. Although prompt EGM signal disappearance is observed immediately after PFA application in the pulmonary veins, whether this finding results in adequate transmural lesions is unknown. STUDY AIM: If application repetition and catheter-tissue contact impact on lesion formation during PFA. METHODS: A circular loop PFA catheter was used to deliver repeated energy applications with various levels of contact-force. A benchtop vegetal potato model and a beating heart ventricular myocardial model were utilized to evaluate the impact of application repetition, contact force, and catheter repositioning on contiguity and lesion depth. Lesion development occurred over 18 hours in the vegetal model and over 6 hours in the porcine model. RESULTS: Lesion formation was found to be dependent on application repetition and contact. In porcine ventricles, single and multiple stacked applications led to a lesion depth of 3.5 ± 0.7 mm and 4.4 ± 1.3 mm, respectively (p =0.002). Furthermore, the greater the catheter-tissue contact, the more contiguous and deeper the lesions in the vegetal model (1.0±0.9 mm with no contact Vs. 5.4±1.4 mm with 30 g of force; p=.0001). CONCLUSION: PFA delivered via a circular catheter showed that both repetition and catheter contact led independently to deeper lesion formation. These findings indicate that endpoints for effective PFA ablation are more related to PFA biophysics than mere EGM attenuation.

Ultrafiltration of Rapeseed Protein Concentrate: Effect of Pectinase Treatment on Membrane Fouling.

Membrane filtration technologies have shown great potential as a gentle and effective method for concentrating and fractionating proteins for food applications. However, the application of this technology to plant-derived protein streams is in its infancy. In this study, an aqueous rapeseed protein concentrate was obtained with wet milling, and its performance during ultrafiltration with two distinct molecular weight cut-offs (10 and 100 kDa) was tested. All rapeseed proteins were retained during filtration. The addition of pectinase during extraction prior to filtration caused important structural modifications to the extract, resulting in increased permeate fluxes, increased carbohydrate permeation and a reduction in irreversible fouling. Lager pore sizes led to more pronounced fouling. FTIR analysis of the spent membranes showed that proteins and lipids are causing irreversible fouling.

Evaluation of lavender and rose aromatherapies on the success of inferior alveolar nerve block in symptomatic irreversible pulpitis: A randomized clinical trial.

Trial design: This is a prospective, block-randomized, blinded, multiple arm and parallel-group superiority clinical trial. Methods: Seventy-eight patients satisfying the recruitment standards, were randomly allocated into three groups as follows: Group I (n = 26) - Inferior alveolar nerve block (IANB) devoid of aromatherapy (AT); Group II (n = 26) - IANB with lavender AT and Group III - IANB with rose AT (n = 26) with the help of the ultrasonic aroma diffuser (with respective oils)for 20 min/2 h in operatories 1,2 and 3 respectively. For AT, 3-4 drops of lavender and rose-conditioned oils were added from a 100 ml solution containing 100 mg of these medicinal plants. The pre-operative (PRO) and access opening (AO) pain as well as the anxiety of patients were recorded using the Visual Analog Scale (VAS) and Modified Dental Anxiety Scale (MDAS) respectively. Data thus obtained was entered into the Excel sheet and subjected to statistical tests (analysis of variance and paired t-test). The p-value less than 0.05 was considered statistically significant. Results: Group I showed non-significant disparity between PRO and AO for both VAS as well as MDAS (p = 0.62, p = 0.71). However, group II (p = 0.04, p = 0.02) and group III (p = 0.03, p = 0.01) revealed significant differences between PO - AO VAS and MDAS. MDAS and VAS intergroup comparison revealed a significant difference among groups I and II (p = 0.03, p = 0.04), and groups I and III (p = 0.02, p = 0.03). However non-significant disparity was observed among groups II and III (p = 0.85, 0.34). Moreover, there was a statistically significant reduction in anxiety levels in females compared to males after rose AT (p = 0.02). Nevertheless, groups I and II did not show any gender predilection for anxiety as well as pain. Conclusion: Alleviation of dental anxiety as well as reduction in pain during AO of teeth with SIP can be achieved using Lavender and rose AT. In female patients, rose AT can be preferred over lavender AT.

Pulsed Field Ablation for Atrial Fibrillation: Mechanisms, Advantages, and Limitations.

Pulsed field ablation with irreversible electroporation for the treatment of atrial fibrillation involves tissue-specific and non-thermal energy-induced cell necrosis, which helps avoid complications, such as pulmonary vein stenosis, atrial collateral tissue damage, and extensive atrial structural damage, often encountered with traditional thermal ablation. In existing clinical trials, pulsed field ablation has shown excellent effects on pulmonary vein isolation in patients with paroxysmal and persistent atrial fibrillation. Pulsed field ablation is easy, simple, and quick and can reduce iatrogenic injury. Therefore, the application of pulsed field ablation technology in the treatment of atrial fibrillation has a promising future. Notably, the adjustment of parameters in pulsed field ablation with different ablation catheter systems can strongly affect the area and depth of the necrotic myocardium, which greatly affects the likelihood of atrial fibrillation recurrence and incidence of adverse complications after ablation. In this paper, we review the mechanisms, advantages, and limitations of pulsed field ablation based on the results of a series of previous studies and provide ideas and directions for future research.

Irreversible Electroporation Margin Accentuation in Pancreaticoduodenectomy: A Propensity Score Matching Analysis.

BACKGROUND: Margin accentuation using irreversible electroporation (MA-IRE) improves recurrence and overall survival (OS) in pancreatic cancer patients; however, there have been limited outcome comparisons to similarly risked patients who did not receive MA-IRE. METHODS: Patients with borderline resectable or locally advanced pancreatic adenocarcinoma who underwent a pancreaticoduodenectomy (PD) between 2017 and 2022 were included. Those who did not receive neoadjuvant chemotherapy for major vessel involvement were excluded. One-to-one propensity score matching (PSM) was used to match the MA-IRE group with the corresponding non-MA-IRE control group with similar risk factors. RESULTS: A total of 36 patients were included in this study. Seventeen (47.2%) patients who underwent MA-IRE matched with 19 control patients (52.8%) with similar risk factors who did not have MA-IRE. Before matching, OS and disease-free survival (DFS) were comparable between the MA-IRE and non-MA-IRE groups. After matching, the MA-IRE group showed improved OS (746 vs. 509 days, hazard ratio 0.313; p = 0.034) compared with the non-MA-IRE group. DFS (p = 0.768), negative margin status (p = 0.317), and 30-day complication rates (p = 1.000) remained statistically different between the groups. CONCLUSIONS: MA-IRE in PD results in longer OS but does not impact margin status, DFS, or postoperative complication rates in our cohort. These findings suggest that MA-IRE is safe and potentially promotes immune cell activation rather than upfront margin mitigation.

Consensus Guidelines of Irreversible Electroporation for Pancreatic Tumors: Protocol Standardization Using the Modified Delphi Technique.

Since no uniform treatment protocol for pancreatic irreversible electroporation (IRE) exists, the heterogeneity throughout literature complicates the comparison of results. To reach agreement among experts, a consensus study was performed. Eleven experts, recruited according to predefined criteria regarding previous IRE publications, participated anonymously in three rounds of questionnaires according to a modified Delphi technique. Consensus was defined as having reached ≥80% agreement. Response rates were 100, 64, and 64% in rounds 1 to 3, respectively; consensus was reached in 93%. Pancreatic IRE should be considered for stage III pancreatic cancer and inoperable recurrent disease after previous local treatment. Absolute contraindications are ventricular arrhythmias, implantable stimulation devices, congestive heart failure NYHA class 4, and severe ascites. The inter-electrode distance should be 10 to 20 mm and the exposure length should be 15 mm. After 10 test pulses, 90 treatment pulses of 1,500 V/cm should be delivered continuously, with a 90-µs pulse length. The first postprocedural contrast-enhanced computed tomography should take place 1 month post-IRE, and then every 3 months. This article provides expert recommendations regarding patient selection, procedure, and follow-up for IRE treatment in pancreatic malignancies through a modified Delphi consensus study. Future studies should define the maximum tumor diameter, response evaluation criteria, and the optimal number of preoperative FOLFIRINOX cycles.

Effect of the Irrigation Agitation Technique on Postoperative Pain in Teeth With Symptomatic Irreversible Pulpitis.

Introduction Irrigation of the root canal system is a vital step in endodontic treatment aimed at disinfecting the canal. The efficacy of irrigation can be improved by various irrigation agitation methods. One such novel method of interest is the manual dynamic agitation (MDA) technique. However, the effect of MDA on postoperative pain as compared to needle irrigation (NI) with sodium hypochlorite has been scarcely explored. This study aimed to compare the effects of NI and MDA techniques on postoperative pain in teeth with symptomatic irreversible pulpitis. Materials and methods This quasi-experimental study was conducted at the Department of Operative and Paediatric Dentistry, Fauji Foundation Dental Hospital, over four months after gaining ethical approval. One hundred and sixty-eight participants diagnosed with symptomatic irreversible pulpitis were enrolled in the study through the purposive sampling technique. The participants were divided into two groups based on the irrigation technique used: Group A (NI) and Group B (MDA). Postoperative pain was recorded after six hours, 24 hours, 48 hours, and seven days using the 0-100mm visual analog scale (VAS). The VAS scores were compared using an independent sample t-test. Results Out of 168 participants, 48.2% were in Group A and 51.2% in Group B. The study found that VAS pain scores for Group B (MDA) were significantly lower at six hours, 24 hours, 48 hours, and seven days as compared to Group A (NI), with a p-value less than 0.001. Conclusion This study shows that the MDA technique leads to decreased postoperative pain both immediately after endodontic treatment and a week later as compared to the NI technique. Hence, the use of MDA can aid in controlling postendodontic pain and, therefore, ensure smoother recovery and increased patient satisfaction.

Robust and Irreversible Sortase-Mediated Ligation by Empolyment of Sarkosyl.

Sortase-mediated ligation (SML) is a widely used method for peptide and protein ligation due to ease of substrate preparation and fast enzymatic kinetics. But there are drawbacks that limit broader applications. Sorting motif in substrates may not be exposed to sortase efficiently due to folding or aggregation. In addition, the ligation is reversible under transpeptidation equilibrium that restricts ligation yield. Here we report a simple but robust method to overcome such limitations. By employment of sarkosyl, the detergent alters substrate conformation to raise sorting motif accessibility for sortase catalysis. Moreover, transpeptidation becomes irreversible presumably by formation of micelle to shield ligation products from sortase. In consequence, excellent yields were achieved from sortase variants with different substrate specificity. Notably, this method is compatible with peptides or proteins capable of forming liquid-liquid phase separation (LLPS), presenting a powerful approach for the conjugation of aggregation-prone substrates. Therefore, we believe the sarkosyl-enhanced SML could be widely applied in peptide and protein chemistry and the unique irreversible transpeptidation mechanism offers an insight to detergent-driven equilibrium.

Advanced treatment and reuse of dye wastewater using thermo-irreversible on/off switch starch with disruption of dissolution/precipitation dynamic equilibrium.

The development of irreversible on/off switching materials is a potential strategy for unidirectional capture and encapsulation of pollutants, preventing the pollutant leakage problem resulting from the reversible dissolution of flocculants. Herein, a thermo-irreversible on/off switch starch (TISS) is prepared through modifying starch by etherification grafting glycidyl phenyl ether and 2,4-bis(dimethylamino)-6-chloro-[1,3,5]-triazine. It breaks the dissolution/precipitation dynamic equilibrium across heating-cooling cycles by thermal-induced irreversible coil-to-globule self-assembly of polymer chains, resulting in a 50-fold decrease in polymer solubility. Particularly, TISS shows a superior double-locking effect on pollutants and flocculants through its unique irreversible conformation memory capability, leading to a high-quality reuse water. 99.9 % of reactive brilliant red dye and 97.9 % of TISS remain fixed within sludge flocs even after prolonged immersion in cold water at 24 °C for 60 days. Furthermore, direct recycling and reuse of dye-bath energy can be realized through the isothermal flocculation and dyeing method, showing a 75 % decrease in energy consumption after three cycles compared to traditional dyeing techniques. This work presents a novel approach to constructing an irreversible pollutant delivery system using thermo-irreversible on/off switch starch, addressing the problems of high energy dissipation and water quality fluctuations during wastewater treatment.

Linkage-Mixed Covalent Organic Frameworks Synthesized by a Liquid-Solid Two-Phase Strategy for Photoenhanced Uranium Extraction.

Synthesizing COFs with hybrid linkage coupling with both reversible and irreversible natures remains a challenging issue. Herein, we report the synthesis of two rare COFs constructed by both reversible and irreversible linkages through a liquid-solid two-phase strategy. A systematic study reveals a one-pot, two-step reaction mechanism for the two COFs, the first step being a reversible Schiff base reaction and the second step being an irreversible Knoevenagel reaction. Interestingly, this hybrid linkage COF is found to show an outstanding photoenhanced uranium extraction performance. The results not only provide a general and green approach to develop the linkage chemistry of COFs but also enrich the synthesis toolboxes and application of COFs.

Remodeling tumor-associated macrophage for anti-cancer effects by rational design of irreversible inhibition of mitogen-activated protein kinase-activated protein kinase 2.

Mitogen-activated protein kinase-activated protein kinase 2 (MK2) emerges as a pivotal target in developing anti-cancer therapies. The limitations of ATP-competitive inhibitors, due to insufficient potency and selectivity, underscore the urgent need for a covalent irreversible MK2 inhibitor. Our initial analyses of The Cancer Genome Atlas database revealed MK2's overexpression across various cancer types, especially those characterized by inflammation, linking it to poor prognosis and highlighting its significance. Investigating MK2's kinase domain led to the identification of a unique cysteine residue, enabling the creation of targeted covalent inhibitors. Compound 11 was developed, demonstrating robust MK2 inhibition (IC50 = 2.3 nM) and high selectivity. It binds irreversibly to MK2, achieving prolonged signal suppression and reducing pathological inflammatory cytokines in macrophages. Furthermore, compound 11 or MK2 knockdown can inhibit the tumor-promoting macrophage M2 phenotype in vitro and in vivo. In macrophage-rich tumor model, compound 11 notably slowed growth in a dose-dependent manner. These findings support MK2 as a promising anticancer target, especially relevant in cancers fueled by inflammation or dominated by macrophages, and provide compound 11 serving as an invaluable chemical tool for exploring MK2's functions.

VARIPULSE: A step-by-step guide to pulmonary vein isolation.

INTRODUCTION: The VARIPULSE™ variable-loop circular catheter (VLCC) is a bidirectional, multielectrode catheter that can perform electrophysiological mapping and deliver pulsed field energy through the TRUPULSE™ Generator for the treatment of atrial fibrillation. This ablation system, including the CARTO 3™ three-dimensional electroanatomical mapping system, represents a fully integrated system. METHODS: Pulsed field ablation (PFA) is a novel, primarily cardiac tissue-selective ablation technology with a minimal thermal effect, potentially eliminating the collateral tissue damage associated with radiofrequency ablation or cryoablation. Integration of a mapping system may lead to shorter fluoroscopy times and improve the usability of the system, allowing tracking of energy density and placement to confirm no areas around the vein are left untreated. RESULTS: This step-by-step review covers patient selection, mapping, the step-by-step ablation workflow, details on catheter repositioning and ensuring contact, considerations for ablation of specific anatomical variations, and discussion of ablation without fluoroscopy based on our initial clinical experience. CONCLUSIONS: The VLCC is part of the fully integrated PFA system designed for pulmonary vein isolation, using mapping to guide catheter placement and lesion set creation. The current workflow, which is based on our initial clinical experience, may be further refined as the PFA system is used in real-world settings.

Prospective Evaluation of a Modified Apnea Test in Brain Death Candidates that Does Not Require Disconnection from the Ventilator.

BACKGROUND: The apnea test (AT) is an important component in the determination of brain death/death by neurologic criteria (BD/DNC) and often entails disconnecting the patient from the ventilator followed by tracheal oxygen insufflation to ensure adequate oxygenation. To rate the test as positive, most international guidelines state that a lack of spontaneous breathing must be demonstrated when the arterial partial pressure of carbon dioxide (PaCO2) ≥ 60 mm Hg. However, the loss of positive end-expiratory pressure that is associated with disconnection from the ventilator may cause rapid desaturation. This, in turn, can lead to cardiopulmonary instability (especially in patients with pulmonary impairment and diseases such as acute respiratory distress syndrome), putting patients at increased risk. Therefore, this prospective study aimed to investigate whether a modified version of the AT (mAT), in which the patient remains connected to the ventilator, is a safer yet still valid alternative. METHODS: The mAT was performed in all 140 BD/DNC candidates registered between January 2019 and December 2022: after 10 min of preoxygenation, (1) positive end-expiratory pressure was increased by 2 mbar (1.5 mm Hg), (2) ventilation mode was switched to continuous positive airway pressure, and (3) apnea back-up mode was turned off (flow trigger 10 L/min). The mAT was considered positive when spontaneous breathing did not occur upon PaCO2 increase to ≥ 60 mm Hg (baseline 35-45 mm Hg). Clinical complications during/after mAT were documented. RESULTS: The mAT was possible in 139/140 patients and had a median duration of 15 min (interquartile range 13-19 min). Severe complications were not evident. In 51 patients, the post-mAT arterial partial pressure of oxygen (PaO2) was lower than the pre-mAT PaO2, whereas it was the same or higher in 88 cases. In patients with pulmonary impairment, apneic oxygenation during the mAT improved PaO2. In 123 cases, there was a transient drop in blood pressure at the end of or after the mAT, whereas in 12 cases, the mean arterial pressure dropped below 60 mm Hg. CONCLUSIONS: The mAT is a safe and protective means of identifying patients who no longer have an intact central respiratory drive, which is a critical factor in the diagnosis of BD/DNC. Clinical trial registration DRKS, DRKS00017803, retrospectively registered 23.11.2020, https://drks.de/search/de/trial/DRKS00017803.

Pulsed-field ablation: An alternative ablative method for gastric electrophysiological intervention.

Pulsed-field ablation (PFA) is an emerging ablative technology that has been used successfully to eliminate cardiac arrhythmias. As a non-thermal technique it has significant benefits over traditional radio-frequency ablation with improved target tissue specificity and reduced risk of adverse events during cardiac applications. We investigated whether PFA is safe for use in the stomach and whether it could modulate gastric slow waves. Female weaner pigs were fasted overnight before anesthesia was induced using tiletamine hydrochloride (50 mg mL-1) and zolazepam hydrochloride (50 mg mL-1) and maintained with propofol (Diprivan 2%, 0.2­0.4 mg kg­1 min­1). Pulsed-field ablation was performed on their gastric serosa in vivo. Adjacent point lesions (n=2-4) were used to create a linear injury using bipolar pulsed-field ablation consisting of 40 pulses (10 Hz frequency, 0.1 ms pulse width, 1000 V amplitude). High-resolution electrical mapping defined baseline and post-ablation gastric slow-wave patterns. A validated five-point scale was used to evaluate tissue damage in hematoxylin and eosin stained images. Results indicated that PFA successfully induced complete conduction blocks in all cases, with lesions through the entire thickness of the gastric muscle layers. Consistent post-ablation slow-wave patterns emerged immediately following ablation and persisted over the study period. Pulsed-field ablation induces rapid conduction blocks as a tool to modulate slow-wave patterns, indicating it may be suitable as an alternative to radio-frequency ablation.

Probing Dual Covalent Irreversible Inhibition of EGFR/FGFR4 by Electrophilic-Based Natural Compounds to Overcome Resistance and Enhance Combination Therapeutic Potentials and Management of Hepatocellular Carcinoma (HCC).

Hepatocellular carcinoma (HCC) is one of the most prevalent cancer types in the world and accounts for the majority of cases of primary liver cancer. A crucial part of the carcinogenesis of HCC involves aberrant stimulation of the FGF19-FGFR4 signaling pathway. Therefore, FGFR4 inhibition has become a strategic therapeutic approach for the treatment of HCC. However, the clinical treatment procedure is significantly hampered by the prevalence of kinase inhibitors resistance. It was recently established that the activation of EGFR signaling was found to be one of the primary mechanisms mediating the acquired resistance to FGFR4 inhibitors, moreover, sensitivity to FGFR4 inhibitors was effectively restored by inhibiting EGFR. These results provide compelling evidence that dual inhibition of EGFR and FGFR4 could represent a viable therapeutic approach to overcome resistance, hence enhanced management of HCC. To this end, we proposed a dual irreversible inhibition strategy through covalent binding by naturally occurring electrophilic warhead-bearing compounds (curcumin, deoxyelephantopin, eupalmerin acetate, syringolin A and andrographolide) to covalently target both EGFR and FGFR4 through cysteine residues, Cys797 and Cys552, respectively. Covalent docking and covalent molecular dynamics (MM/MDcov) simulations combined with thermodynamic binding free energy calculations were performed, and the results were compared against known potent and selective covalent EGFR and FGFR4 inhibitors with available X-ray crystal structures, Afatinib and BLU9931, respectively. Curcumin, deoxyelephantopin, eupalmerin acetate, syringolin A, and andrographolide showed relative binding free energies of -22.85, -17.14, -12.98, -21.81, and - 19.00 kcal/mol against EGFR and - 41.06, -29.45, -24.76, -40.11, and - 37.55 kcal/mol against FGFR4, respectively. The mechanisms of binding were emphasized by hydrogen bonding and binding forces analysis as well as active site physicochemical profiling. The findings of this study identified that curcumin, syringolin A and andrographolide-but not eupalmerin acetate or deoxyelephantopin -could be viable dual EGFR and FGFR4 covalent irreversible inhibitors and could be implemented in HCC combination therapy protocols alone or in conjunction with other chemotherapeutic agents. Investigations of this study conclusively indicate dual blockade of EGFR and FGFR4 may be a promising future therapeutic strategy for enhanced management of HCC.

Elective full pulpotomy in mature permanent teeth diagnosed with symptomatic irreversible pulpitis: a two years retrospective study.

AIM: To investigate the outcome of elective full pulpotomy, using calcium silicate-based cements (CSBC), after 2 years, in symptomatic mature permanent teeth with carious lesions, diagnosed as irreversible pulpitis, and analyse the capacity of Wolters et al. (2017) classification to predict the likelihood of treatment failure. METHODS: The treatment records of 56 patients with symptomatic mature teeth with carious lesions, diagnosed as irreversible pulpitis and treated by elective full pulpotomy, using CSBCs as pulp capping materials, were reviewed. Thirteen teeth were excluded. The remaining 43 teeth were evaluated retrospectively at 24 months. Fisher`s exact test with the Lancaster's mid-P adjustment was used to assess different outcomes amongst the diagnostic categories. RESULTS: Four of the cases failed before 24 months and required root canal treatment (RCT). Overall success rate at 2 years was 90.7% (39 of 43). An inverse, but non-significant, correlation was observed between the severity of pulpitis according to the Wolters classification and the treatment success rate (p > 0.05). The type of CSBC used was associated to the success rate (OR = 10.5; 95% C.I. = 0.5 - 207.4; p = 0.027), being 82% with Endosequence and 100% with Biodentine. Postoperative pain associated significantly to lower success rate (66.7%) (Odds ratio = 8.0; 95% C.I. = 0.7 - 95.9; p = 0.047). CONCLUSIONS: Elective full pulpotomy using a CSBC was a successful choice for the treatment of mature permanent teeth with symptoms indicative of irreversible pulpitis. There were no significant differences between the success rate of mild, moderate and severe pulpitis. Postoperative pain could be considered a risk marker for failure of full pulpotomy. The term "irreversible pulpitis" should be re-signified to indicate the need for access to the pulp chamber, rather than an indication for extraction or RCT.