Extracellular Vesicle and Particle Biomarkers Define Multiple Human Cancers.

There is an unmet clinical need for improved tissue and liquid biopsy tools for cancer detection. We investigated the proteomic profile of extracellular vesicles and particles (EVPs) in 426 human samples from tissue explants (TEs), plasma, and other bodily fluids. Among traditional exosome markers, CD9, HSPA8, ALIX, and HSP90AB1 represent pan-EVP markers, while ACTB, MSN, and RAP1B are novel pan-EVP markers. To confirm that EVPs are ideal diagnostic tools, we analyzed proteomes of TE- (n = 151) and plasma-derived (n = 120) EVPs. Comparison of TE EVPs identified proteins (e.g., VCAN, TNC, and THBS2) that distinguish tumors from normal tissues with 90% sensitivity/94% specificity. Machine-learning classification of plasma-derived EVP cargo, including immunoglobulins, revealed 95% sensitivity/90% specificity in detecting cancer. Finally, we defined a panel of tumor-type-specific EVP proteins in TEs and plasma, which can classify tumors of unknown primary origin. Thus, EVP proteins can serve as reliable biomarkers for cancer detection and determining cancer type.

Integrative toolbox to assess the quality of freshwater sediments contaminated with potentially toxic metals.

The Guadiana Basin is a transnational basin, presenting historical contamination with potentially toxic metals (PTM), which origin can be both natural and anthropogenic. This study explores the use of a set of observational, chemical and ecotoxicological assays with Heterocypris incongruens, Vibrio fischeri, Pseudokirchneriella subcapitata, Thamnocephalus platyurus, identifying the most sensitive to be included in a toolbox to analyze the quality of freshwater sediments related to this type of contamination. The study included the analysis of a reservoir and streams sediments of Guadiana basin, in two consecutive years with different climate conditions 2017 (dry year) and 2018 (normal year). The results showed high chemical variability along the basin, with greater contamination with PTM in the reservoir sediments. The calculated Enrichment Factors (EF) indicated high anthropogenic contamination by Cd, followed by Pb (EF > 1.5). The geoaccumulation index (Igeo) revealed that the sediments were severely polluted with Cd, and slightly polluted with Pb and Cu, inducing a higher sublethal toxicity to Heterocypris incongruens. Among the parameters evaluated, and after the use of multivariate statistical techniques, the toolbox for assessing sediments quality, in similar climate and geological conditions, should include the analysis of: meteorology, land use/cover in the area, granulometry, organic matter content, PTM concentrations, contamination indices (e.g., Igeo and EF), and sublethal bioassays with H. incongruens (total sediment analysis) and Vibrio fisheri luminescence inhibition (pore water analysis).

Tumour exosome integrins determine organotropic metastasis.

Ever since Stephen Paget's 1889 hypothesis, metastatic organotropism has remained one of cancer's greatest mysteries. Here we demonstrate that exosomes from mouse and human lung-, liver- and brain-tropic tumour cells fuse preferentially with resident cells at their predicted destination, namely lung fibroblasts and epithelial cells, liver Kupffer cells and brain endothelial cells. We show that tumour-derived exosomes uptaken by organ-specific cells prepare the pre-metastatic niche. Treatment with exosomes from lung-tropic models redirected the metastasis of bone-tropic tumour cells. Exosome proteomics revealed distinct integrin expression patterns, in which the exosomal integrins α6ß4 and α6ß1 were associated with lung metastasis, while exosomal integrin αvß5 was linked to liver metastasis. Targeting the integrins α6ß4 and αvß5 decreased exosome uptake, as well as lung and liver metastasis, respectively. We demonstrate that exosome integrin uptake by resident cells activates Src phosphorylation and pro-inflammatory S100 gene expression. Finally, our clinical data indicate that exosomal integrins could be used to predict organ-specific metastasis.

Targeted gene knock-in by homology-directed genome editing using Cas9 ribonucleoprotein and AAV donor delivery.

Realizing the full potential of genome editing requires the development of efficient and broadly applicable methods for delivering programmable nucleases and donor templates for homology-directed repair (HDR). The RNA-guided Cas9 endonuclease can be introduced into cells as a purified protein in complex with a single guide RNA (sgRNA). Such ribonucleoproteins (RNPs) can facilitate the high-fidelity introduction of single-base substitutions via HDR following co-delivery with a single-stranded DNA oligonucleotide. However, combining RNPs with transgene-containing donor templates for targeted gene addition has proven challenging, which in turn has limited the capabilities of the RNP-mediated genome editing toolbox. Here, we demonstrate that combining RNP delivery with naturally recombinogenic adeno-associated virus (AAV) donor vectors enables site-specific gene insertion by homology-directed genome editing. Compared to conventional plasmid-based expression vectors and donor templates, we show that combining RNP and AAV donor delivery increases the efficiency of gene addition by up to 12-fold, enabling the creation of lineage reporters that can be used to track the conversion of striatal neurons from human fibroblasts in real time. These results thus illustrate the potential for unifying nuclease protein delivery with AAV donor vectors for homology-directed genome editing.

Successful Treatment of Endometriosis-Related Hemorrhagic Ascites: A Report of Three Cases.

Endometriosis-related ascites is rare and is frequently confused with an ovarian malignancy. Since it affects women in reproductive age, its diagnosis and therapy are even more challenging. These patients usually present with abdominal distension, pelvic pain, and weight loss, but a careful questioning usually reveals the typical endometriosis symptoms-such as dysmenorrhea and dyspareunia. We present three cases of endometriosis-related ascites, one of them with pleural effusion. All cases were associated with extensive disease and required laborious laparoscopic surgery, medical therapy with gonadotropin releasing hormone analogs, and long-term follow-up. One of the patients delivered twins following an in vitro fertilization (IVF) cycle without recurrence of ascites. We aim to raise awareness toward the importance of considering endometriosis in a patient with ascites of unknown origin.

Hydrogen peroxide regulates angiogenesis-related factors in tumor cells.

Tumor angiogenesis is required for tumor development and growth, and is regulated by several factors including ROS. H2O2 is a ROS with an important role in cell signaling, but how H2O2 regulates tumor angiogenesis is still poorly understood. We have xenografted tumor cells with altered levels of H2O2 by catalase overexpression into zebrafish embryos to study redox-induced tumor neovascularization. We found that vascular recruitment and invasion were impaired if catalase was overexpressed. In addition, the overexpression of catalase altered the transcriptional levels of several angiogenesis-related factors in tumor cells, including TIMP-3 and THBS1. These two anti-angiogenic factors were found to be H2O2-regulated by two different mechanisms: TIMP-3 expression in a cell-autonomous manner; and, THBS1 expression that was non-cell-autonomous. Our work shows that intracellular H2O2 regulates the expression of angiogenic factors and the formation of a vessel network. Understanding the molecular mechanisms that govern this multifunctional effect of H2O2 on tumor angiogenesis could be important for the development of more efficient anti-angiogenic therapies.

Influence of interhospital transfer on outcomes of symptomatic and ruptured abdominal aortic aneurysms.

Objetive: Evaluate the influence of the geographic location of patients with symptomatic abdominal aortic aneurysms (AAA) or ruptured AAA (rAAA), on mortality. METHODS: Retrospective review of all cases of symptomatic AAA and rAAA submitted to surgery in a tertiary institution, between January 2011 and August 2017. The main outcome was in-hospital mortality. Secondary outcomes were admission to intensive care unit (ICU), length of ICU and hospital stay, type of repair and anesthesia and weekend presentation. Data was submitted to univariable analysis and logistic regression. Statistical significance was considered if the p value was <0.05. RESULTS: 135 patients were admitted with the diagnosis of symptomatic or rAAA and submitted to surgery, 83 (61.5%) by endovascular repair and 52 (38.5%) by open repair, 30.4% with local anesthesia and sedation. 92 patients (68.1%) were transferred from other hospitals, with a mean distance of 113±88 km. Subgroup analysis revealed that there were no significant differences between transferred and not transferred patients' groups concerning main outcome (31.5% vs 34.9%, p=0.35), baseline characteristics (age and gender), type of surgery and anesthesia, weekend presentation, ICU admission, length of ICU and hospital stay. Logistic regression analysis revealed that the variables associated with mortality were female gender (odds ratio [OR] 2.28; 95% confidence interval [CI] 1.40-3.70; p<0.01), open repair (OR 2.79; 95% CI 1.68-4.63; p<0.01) and general anesthesia (OR 9.16; 95% CI 2.33-36.06; p<0.01). CONCLUSION: Our study revealed that interhospital transfer of patients for urgent repair of AAA was not associated with an increased mortality.

Objetivo: Avaliar a influência da localização geográfica dos doentes com aneurismas da aorta abdominal (AAA) sintomáticos ou rotos (rAAA), na mortalidade. Métodos: Revisão retrospetiva de todos os casos de AAA sintomáticos ou rAAA submetidos a cirurgia numa instituição terciária, entre Janeiro 2011 e Agosto 2017. O outcome primário foi a mortalidade intrahospitalar. Os outcomes secundários foram a admissão em unidade de cuidados intensivos (UCI), duração do internamento na UCI e hospitalar, tipo de cirurgia e anestesia e a apresentação ao fim-de-semana. Os dados foram submetidos a análise univariável e regressão logística. Foi considerado um valor estatisticamente significativo quando o valor de p <0.05. Resultados: 135 doentes foram admitidos com o diagnóstico de AAA sintomático ou rAAA e submetidos a cirurgia, 83 (61.5%) por via endovascular e 52 (38.5%) por via convencional, 30.4% com anestesia local e sedação. 92 doentes (68.1%) foram transferidos de outros hospitais, com uma distância média de 113±88 km. A análise de subgrupos revelou que não existia diferença significativa entre os grupos de doentes transferidos e não transferidos relativamente ao outcome primário (31.5% vs 34.9%, p=0.35), características de base (idade e género), tipo de cirurgia e anestesia, apresentação ao fim-de-semana, admissão na UCI, duração do internamento na UCI e hospitalar. A análise de regressão logística revelou que as variáveis associadas com a mortalidade foram o género feminino (odds ratio [OR] 2.28; 95% intervalo de confiança [IC] 1.40- 3.70; p<0.01), cirurgia convencional (OR 2.79; 95% IC 1.68-4.63; p<0.01) e anestesia geral (OR 9.16; 95% IC 2.33- 36.06; p<0.01). Conclusão: Este estudo revelou que a transferência interhospitalar de doentes para a reparação cirúrgica urgente de AAA não está associada a aumento da mortalidade.

Infrarenal Abdominal Penetrating Aortic Ulcer, an Atypical Location of a Rare Disease.

INTRODUCTION: Penetrating aortic ulcer (PAU) is classically included in acute aortic syndromes, together with aortic dissection and intramural hematoma. These three disorders are considered different stages of the same disease. PAU is the result of medial degeneration with disruption of the intima, mainly due to atherosclerotic risk factors. Most of them are located on descending thoracic aorta and only a few small series and case reports demonstrate location on infrarenal abdominal aorta. Clinical presentation varies in spectrum, from asymptomatic to fatal aortic rupture. Treatment options include medical therapy, particularly strict blood pressure control, and surgical approach. Nowadays endovascular exclusion is commonly performed, although open surgical reconstruction remains the gold standard. METHODS: Report a case of endovascular repair of an infrarenal abdominal PAU. RESULTS: A 72-year-old man, with hypertension, type 2 diabetes, hypercholesterolemia, lumbar osteoarthrosis, was referred to Vascular Surgery outpatient clinic with the diagnosis of infrarenal abdominal PAU on a Computed Tomography Angiography (CTA). This exam was performed due to chronic lumbar complaints from lumbar osteoarthrosis. The patient denied any other complaint. Physical examination was normal. A thoraco-abdomino-pelvic CTA revealed two sites of PAU in the infrarenal aorta with 10mm and 21mm of depth and associated aortic enlargement of 39mm maximum diameter. This exam revealed an enlargement of the depth of the PAU and the aorta diameter in 2 and 3mm, respectively, in the course of 2 months. An EVAR was performed, in a standard aorto-biiliac fashion. The post-operative period was uneventful and the patient discharged 3 days later. 1 month after the surgery, patient remained asymptomatic and the follow-up CTA demonstrated exclusion of both PAU, no endoleaks and stability of aortic diameter. A long term follow-up should be maintained, as for regular EVAR. CONCLUSION: PAU is a rare clinical entity, with infrarenal abdominal aorta location even scarcer. Asymptomatic patient must be regularly followed and threshold to treatment low, bearing in mind the possible catastrophic evolution of the disease. Endovascular approach should be considered as a first approach, considering the technical feasibility and the comorbidities associated with this elderly population.

Influence of Interhospital Transfer on Outcomes of Symptomatic and Ruptured Abdominal Aortic Aneurysms.

INTRODUCTION: Symptomatic or ruptured abdominal aortic aneurysms (rAAA) maintains a high mortality index despite technical advances in its treatment. The influence of patients' geographic location on rAAA outcomes, when the rupture occurs or when the AAA becomes symptomatic, has not been a commonly studied issue. Due to the lack of research on this matter, the impact of interhospital transfer on mortality is ambiguous. OBJECTIVE: Evaluate the influence of the geographic location of patients with symptomatic AAA or rAAA on AAA mortality. METHODS: Retrospective review of all cases of symptomatic AAA and rAAA submitted to surgery in a tertiary institution, between January 2011 and August 2017. The main outcome was in-hospital mortality. Secondary outcomes were admission to intensive care unit (ICU), length of ICU and hospital stay, type of repair and anesthesia and weekend presentation. Data was submitted to univariable analysis and logistic regression. Statistical significance was considered if the p value was <0.05. RESULTS: During the defined period of 80 months, a total of 135 patients were admitted with the diagnosis of symptomatic or rAAA and submitted to surgery. Most patients had a ruptured AAA (90.4%, n=122), while symptomatic AAA represented a minority (9.6%, n=13). All patients (91.1% male gender, mean age 74±10 years) were submitted to surgery, 83 (61.5%) by endovascular repair and 52 (38.5%) by open repair, 30.4% with local anesthesia and sedation (n=41), all in the endovascular group. 92 patients (68.1%) were transferred from other hospitals, with a mean distance of 113±88 km. In this cohort, in-hospital mortality was 31.5% in transferred patients and 34.9% in not transferred patients. Subgroup analysis revealed that there were no significant differences between transferred and not transferred patients' groups concerning main outcome (p=0.35), baseline characteristics (age and gender), type of surgery and anesthesia, weekend presentation, ICU admission, length of ICU and hospital stay. Logistic regression analysis revealed that the variables associated with mortality were female gender (odds ratio [OR] 2.28; 95% confidence interval [CI] 1.40-3.70; p<0.01), open repair (OR 2.79; 95% CI 1.68-4.63; p<0.01) and general anesthesia (OR 9.16; 95% CI 2.33-36.06; p<0.01). CONCLUSION: Our study revealed that transfer of patients for urgent repair of AAA was not associated with an increased mortality. The hypothetical increased mortality due to transfer might have been compensated by endovascular treatment and local anesthesia in some cases. Further studies must be carried out, particularly comparing endovascular and open repair in emergency setting.

Segmented bimorph mirrors for adaptive optics: morphing strategy.

This paper discusses the concept of a light weight segmented bimorph mirror for adaptive optics. It focuses on the morphing strategy and addresses the ill-conditioning of the Jacobian of the segments, which are partly outside the optical pupil. Two options are discussed, one based on truncating the singular values and one called damped least squares, which minimizes a combined measure of the sensor error and the voltage vector. A comparison of various configurations of segmented mirrors was conducted; it is shown that segmentation sharply increases the natural frequency of the system with limited deterioration of the image quality.

Segmented bimorph mirrors for adaptive optics: segment design and experiment.

We discuss the concept of lightweight segmented bimorph mirrors for adaptive optics. The segment consists of a monocrystal silicon substrate actuated by an array of in-plane piezoceramic (PZT) actuators with honeycomb electrodes. We focus on technological aspects of the segment design that are critical for space applications and describe a single segment demonstrator. The morphing capability of the segment is evaluated experimentally. We also discuss the local deformations (dimples) associated with the shape of the electrodes acting on the PZT array.

Improving eSource Site Start-Up Practices.

Background: eSource software that copies patient electronic health record data into a clinical trial electronic case report form holds promise for increasing data quality while reducing data collection, monitoring and source document verification costs. Integrating eSource into multicenter clinical trial start-up procedures could facilitate the use of eSource technologies in clinical trials. Methods: We conducted a qualitative integrative analysis to identify eSource site start-up key steps, challenges that might occur in executing those steps, and potential solutions to those challenges. We then conducted a value analysis to determine the challenges and solutions with the greatest impacts for eSource implementation teams. Results: There were 16 workshop participants: 10 pharmaceutical sponsor, 3 academic site, and 1 eSource vendor representatives. Participants identified 36 Site Start-Up Key Steps, 11 Site Start-Up Challenges, and 14 Site Start-Up Solutions for eSource-enabled studies. Participants also identified 77 potential impacts of the Challenges upon the Site Start-Up Key Steps and 70 ways in which the Solutions might impact Site Start-Up Challenges. The most important Challenges were: (1) not being able to identify a site eSource champion and (2) not agreeing on an eSource approach. The most important Solutions were: (1) vendors accepting electronic data in the FHIR standard, (2) creating standard content for eSource-related legal documents, and (3) creating a common eSource site readiness checklist. Conclusions: Site start-up for eSource-enabled multi-center clinical trials is a complex socio-technical problem. This study's Start-Up Solutions provide a basic infrastructure for scalable eSource implementation.

Circulating tumor extracellular vesicles to monitor metastatic prostate cancer genomics and transcriptomic evolution.

Extracellular vesicles (EVs) secreted by tumors are abundant in plasma, but their potential for interrogating the molecular features of tumors through multi-omic profiling remains widely unexplored. Genomic and transcriptomic profiling of circulating EV-DNA and EV-RNA isolated from in vitro and in vivo models of metastatic prostate cancer (mPC) reveal a high contribution of tumor material to EV-loaded DNA/RNA, validating the findings in two cohorts of longitudinal plasma samples collected from patients during androgen receptor signaling inhibitor (ARSI) or taxane-based therapy. EV-DNA genomic features recapitulate matched-patient biopsies and circulating tumor DNA (ctDNA) and associate with clinical progression. We develop a novel approach to enable transcriptomic profiling of EV-RNA (RExCuE). We report how the transcriptome of circulating EVs is enriched for tumor-associated transcripts, captures certain patient and tumor features, and reflects on-therapy tumor adaptation changes. Altogether, we show that EV profiling enables longitudinal transcriptomic and genomic profiling of mPC in liquid biopsy.

A mycotic forearm pseudoaneurym as an unusual complication of infective endocarditis.

INTRODUCTION: Mycotic pseudoaneurysms are an infrequent complication of infective endocarditis; most cases are secondary to arterial trauma. The commonest site involved are the intracranial arteries, followed by the abdominal aorta and then the peripheral vessels. CASE PRESENTATION: We report a case of a 36-year-old man, admitted in our institution for a subarachnoid haemorrhage, who presented with fever of unknown origin during his stay in the neurocritical care unit and whom was diagnosed infective endocarditis due to Meticilin Sensible Staphylococcus Aureus. Almost two weeks after antibiotic therapy was instituted, he presented a large, growing, pulsatile mass of the left forearm. A giant pseudoaneurysm arising from the radial artery was detected with ultrasound and surgical intervention was carried out. A large laceration of the radial artery was detected and an interposition of a vein graft was performed. DISCUSSION: Forearm mycotic pseudoaneurysms are rare. A high index of suspicion is needed and they should always be borne in mind in the differential diagnosis of an extremity pain, swelling or motor-sensorial deficit after infective endocarditis.

Late poor outcomes of Clostridioides difficile infections in oncological patients: A multicentre cohort study.

Background: Cancer has been associated with an increased risk of in-hospital mortality in CDI patients. However, data on delayed mortality in cancer patients with CDI are scarce. Aim/Objective: The aim of the present study was to compare outcomes between oncological patients and the general population with Clostridioides difficile infection (CDI) after 90 days of follow-up. Methods: A multicenter prospective cohort study was conducted in 28 hospitals participating in the VINCat program. Cases were all consecutive adult patients who met the case definition of CDI. Sociodemographic, clinical, and epidemiological variables and evolution at discharge and after 90 days were recorded for each case. Findings/results: The mortality rate was higher in oncological patients (OR = 1.70, 95% CI: 1.08-2.67). In addition, oncological patients receiving chemotherapy (CT) presented higher recurrence rates (18.5% vs 9.8%, p = 0.049). Among oncological patients treated with metronidazole, those with active CT showed a higher rate of recurrence (35.3% vs 8.0% p = 0.04). Discussion: Oncological patients presented a higher risk of poor outcomes after CDI. Their early and late mortality rates were higher than in the general population, and in parallel, those undergoing chemotherapy (especially those receiving metronidazole) had higher rates of recurrence.

The efficiency of the EmERGE platform for medically stable people living with HIV in Portugal.

Background: The aim of this study was to calculate the cost-effectiveness of the EmERGE Pathway of Care for medically stable people living with HIV in the Hospital Capuchos, Centro Hospitalar Universitário de Lisboa Central (HC-CHLC). The app enables individuals to receive HIV treatment information and communicate with caregivers. Methods: This before-and-after study collected the use of services data 1 year before implementation and after implementation of EmERGE from November 1, 2016, to October 30, 2019. Departmental unit costs were calculated and linked to mean use of outpatient services per patient-year (MPPY). Annual costs per patient-year were combined with primary (CD4 count; viral load) and secondary outcomes (PAM-13; PROQOL-HIV). Results: Five hundred eighty-six EmERGE participants used HIV outpatient services. Annual outpatient visits decreased by 35% from 3.1 MPPY (95% confidence interval [CI]: 3.0-3.3) to 2.0 (95% CI: 1.9-2.1) as did annual costs per patient-year from €301 (95% CI: €288-€316) to €193 (95% CI: €182-€204). Laboratory tests and costs increased by 2%, and radiology investigations decreased by 40% as did costs. Overall annual cost for HIV outpatient services decreased by 5% from €2093 (95% CI: €2071-€2112) to €1984 (95% CI: €1968-€2001); annual outpatient costs decreased from €12,069 (95% CI: €12,047-€12,088) to €11,960 (95% CI: €11,944-€11,977), with 83% of annual cost because of antiretroviral therapy (ART). Primary and secondary outcome measures did not differ substantially between periods. Conclusions: The EmERGE Pathway produced cost savings after implementation-extended to all people living with HIV additional savings are likely to be produced, which can be used to address other needs. Antiretroviral drugs (ARVs) were the main cost drivers and more expensive in Portugal compared with ARV costs in the other EmERGE sites.

Development of Antifouling Polysulfone Membranes by Synergistic Modification with Two Different Additives in Casting Solution and Coagulation Bath: Synperonic F108 and Polyacrylic Acid.

This study deals with the development of antifouling ultrafiltration membranes based on polysulfone (PSF) for wastewater treatment and the concentration and purification of hemicellulose and lignin in the pulp and paper industry. The efficient simple and reproducible technique of PSF membrane modification to increase antifouling performance by simultaneous addition of triblock copolymer polyethylene glycol-polypropylene glycol-polyethylene glycol (Synperonic F108, Mn =14 × 103 g mol-1) to the casting solution and addition of polyacrylic acid (PAA, Mn = 250 × 103 g mol-1) to the coagulation bath is proposed for the first time. The effect of the PAA concentration in the aqueous solution on the PSF/Synperonic F108 membrane structure, surface characteristics, performance, and antifouling stability was investigated. PAA concentrations were varied from 0.35 to 2.0 wt.%. Membrane composition, structure, and topology were investigated by Fourier-transform infrared spectroscopy (FTIR), X-ray photoelectron spectroscopy (XPS), atomic force microscopy (AFM), and scanning electron microscopy (SEM). The addition of PAA into the coagulation bath was revealed to cause the formation of a thicker and denser selective layer with decreasing its pore size and porosity; according to the structural characterization, an interpolymer complex of the two additives was formed on the surface of the PSF membrane. Hydrophilicity of the membrane selective layer surface was shown to increase significantly. The selective layer surface charge was found to become more negative in comparison to the reference membrane. It was shown that PSF/Synperonic F108/PAA membranes are characterized by better antifouling performance in ultrafiltration of humic acid solution and thermomechanical pulp mill (ThMP) process water. Membrane modification with PAA results in higher ThMP process water flux, fouling recovery ratio, and hemicellulose and total lignin rejection compared to the reference PSF/Synperonic F108 membrane. This suggests the possibility of applying the developed membranes for hemicellulose concentration and purification.

Efficiency of the EmERGE Pathway of Care in Five European HIV Centres.

OBJECTIVE: We aimed to calculate the efficiency of the EmERGE Pathway of Care in five European HIV clinics, developed and implemented for medically stable people living with HIV. METHODS: Participants were followed up for 1 year before and after implementation of EmERGE, between April 2016 and October 2019. Micro-costing studies were performed in the outpatient services of the clinics. Unit costs for outpatient services were calculated in national currencies and converted to US$ 2018 OECD purchasing parity prices to enable between clinic comparisons in terms of outcomes and costs. Unit costs were linked to the mean use of services for medically stable people living with HIV,  before and after implementation of EmERGE. Primary outcome measures were CD4 count and viral load; secondary outcomes were patient activation (PAM13) and quality of life (PROQOL-HIV). Out-of-pocket expenditure data were collected. RESULTS: There were 2251 participants: 87-93% were male, mean age at entry was 41-47 years. Medically stable people living with HIV had outpatient visits in four sites which decreased by 9-31% and costs by 5-33%; visits and costs increased by 8% in one site, which had to revert back to face-to-face visits. Antiretroviral drugs comprised 83-91% of annual costs: the Portuguese site had the highest antiretroviral drug costs in US$ purchasing parity prices. Primary and secondary outcome measures of participants did not change during the study. CONCLUSIONS: EmERGE is acceptable and provided cost savings in different socio-economic settings. Antiretroviral drug costs remain the main cost drivers in medically stable people living with HIV. While antiretroviral drug prices in local currencies did not differ that much between countries, conversion to US$ purchasing parity prices revealed antiretroviral drugs were more expensive in the least wealthy countries. This needs to be taken into consideration when countries negotiate drug prices with pharmaceutical vendors. Greater efficiencies can be anticipated by extending the use of the EmERGE Pathway to people with complex HIV infection or other chronic diseases. Extending such use should be systematically monitored, implementation should be evaluated and funding should be provided to monitor and evaluate future changes in service provision.

Clostridioides difficile infection recurrence in the VINCat hospitals: a prospective observational cohort study.

Background: The 2016 cumulative incidence of Clostridioides difficile infection (CDI) in Spain was reported by the European Center for Disease Control to be above the mean of other European countries. The aim of this multicenter prospective observational cohort study was to examine the risk factors that determine 90-day CDI recurrence in Catalonia, Spain. Methods: The study included 558 consecutive adults admitted to hospital who had a symptomatic, first positive CDI diagnosis. Sociodemographic, clinical and epidemiological variables were recorded. The primary outcome was 90-day CDI recurrence. Results: In this Catalan population, having received more than one course of antibiotics in the 30 days prior to CDI diagnosis (odds ratio: 2.459; 95% CI: 1.195-5.060; p = 0.015) and active chemotherapy (odds ratio: 4.859; 95% CI: 1.495-15.792; p = 0.009) are significant predictors of 90-day CDI recurrence. Conclusion: The identification of independent risk factors of 90-day CDI recurrence will enable the optimization of preventive measures in at-risk populations.

Tumour exosomal CEMIP protein promotes cancer cell colonization in brain metastasis.

The development of effective therapies against brain metastasis is currently hindered by limitations in our understanding of the molecular mechanisms driving it. Here we define the contributions of tumour-secreted exosomes to brain metastatic colonization and demonstrate that pre-conditioning the brain microenvironment with exosomes from brain metastatic cells enhances cancer cell outgrowth. Proteomic analysis identified cell migration-inducing and hyaluronan-binding protein (CEMIP) as elevated in exosomes from brain metastatic but not lung or bone metastatic cells. CEMIP depletion in tumour cells impaired brain metastasis, disrupting invasion and tumour cell association with the brain vasculature, phenotypes rescued by pre-conditioning the brain microenvironment with CEMIP+ exosomes. Moreover, uptake of CEMIP+ exosomes by brain endothelial and microglial cells induced endothelial cell branching and inflammation in the perivascular niche by upregulating the pro-inflammatory cytokines encoded by Ptgs2, Tnf and Ccl/Cxcl, known to promote brain vascular remodelling and metastasis. CEMIP was elevated in tumour tissues and exosomes from patients with brain metastasis and predicted brain metastasis progression and patient survival. Collectively, our findings suggest that targeting exosomal CEMIP could constitute a future avenue for the prevention and treatment of brain metastasis.