Copper-Catalyzed Hydroamination: Enantioselective Addition of Pyrazoles to Cyclopropenes.

Chiral N-cyclopropyl pyrazoles and structurally related heterocycles are prepared using an earth-abundant copper catalyst under mild reaction conditions with high regio-, diastereo-, and enantiocontrol. The observed N2:N1 regioselectivity favors the more hindered nitrogen of the pyrazole. Experimental and DFT studies support a unique mechanism that features a five-centered aminocupration.

Does an Insulin Double-Checking Procedure Improve Patient Safety?

OBJECTIVE: The aim of this study was to examine the effectiveness of a subcutaneous insulin double-checking preparation intervention on insulin administration errors. BACKGROUND: Insulin accounts for 3.5% of medication-related errors. The Joint Commission and Institute for Safe Medication Practices recommend a 2-nurse double-checking procedure when preparing insulin. METHODS: This study used a randomized, controlled, nonblinded, intent-to-treat methodology. RESULTS: In total, 266 patients were enrolled, and over 4 weeks of data collection, there were 5238 opportunities for insulin administration. Overall, 3151 insulin administration opportunities had no errors; the double-checking group had more no-error periods than usual care. Of error types, wrong time was predominant, but less prevalent in the double-checking group. Omission errors were uncommon and occurred less in the double-checking group. CONCLUSIONS: The subcutaneous insulin double-checking preparation procedure led to less insulin administration errors; however, timing errors were most prevalent and are not resolved with double-checking interventions.

Patient-Reported Expedited Partner Therapy for Gonorrhea in the United States: Findings of the STD Surveillance Network 2010-2012.

BACKGROUND: Expedited partner therapy (EPT) has been shown to prevent reinfection in persons with gonorrhea and to plausibly reduce incidence. The Centers for Disease Control and Prevention recommends EPT as an option for treating sex partners of heterosexual patients. Few studies that examine how the reported use of this valuable intervention differs by patient and provider characteristics and by geography across multiple jurisdictions in the United States are currently available. METHODS: Case and patient interview data were obtained for a random sample of reported cases from 7 geographically disparate US jurisdictions participating in the Sexually Transmitted Disease (STD) Surveillance Network. These data were weighted to be representative of all reported gonorrhea cases in the 7 study sites. Patient receipt of EPT was estimated, and multivariate models were constructed separately to examine factors associated with receipt of EPT for heterosexuals and for men who have sex with men. RESULTS: Overall, 5.4% of patients diagnosed and reported as having gonorrhea reported receiving EPT to treat their sex partners. Heterosexual patients were more likely to have received EPT than men who have sex with men at 6.6% and 2.6% of patients, respectively. Receipt of EPT did not vary significantly by race, Hispanic ethnicity, or age for either group, although significant variation was observed in different provider settings, with patients from family planning/reproductive health and STD clinic settings more likely to report receiving EPT. Jurisdiction variations were also observed with heterosexual patients in Washington State most likely (35.5%), and those in New York City, Connecticut, and Philadelphia least likely to report receiving EPT (<2%). CONCLUSIONS: With the exception of one jurisdiction in the STD Surveillance Network actively promoting EPT use, patient-reported receipt of the intervention remains suboptimal across the network. Additional efforts to promote EPT, especially for patients diagnosed in private provider and hospital settings, are needed to realize the full potential of this valuable gonorrhea control intervention.

Neighborhoods at risk: estimating risk of higher Neisseria gonorrhoeae incidence among women at the census tract level.

BACKGROUND: The association between area-based social factors and sexually transmitted diseases has been demonstrated in numerous studies. Such associations have not previously been explored for their potential to quantify likelihood of higher transmission of gonorrhea in small geographic areas. METHODS: Aggregate census tract-level sociodemographic factors in 4 domains (demographics, educational attainment, household income, and housing characteristics) were merged with female gonorrhea incidence data from 113 counties in 10 US states. Multivariate models were constructed, and a tract-level composite gonorrhea risk index was calculated. This composite risk index was validated against gonorrhea incidence among women from 2 independent states. RESULTS: Seven tract-level factors were found to be most strongly correlated with female gonorrhea incidence: educational attainment, proportion of female headed households, annual household income below US $20,000, proportion of population non-Hispanic black, proportion of housing units currently vacant, proportion of population reporting moving in last year, and proportion of households that are nonfamily units. Composite index was highly correlated with female gonorrhea in the study area and validated with independent data. CONCLUSIONS: Social factors predict gonorrhea incidence at the census tract level and identify small areas at risk for higher morbidity. These data may be used by health departments and health care practices to develop geographically based disease prevention and control efforts. This is especially useful because gonorrhea incidence data are not routinely available below the county level in many states.

Predicting Recurrence-Free and Overall Survival for Patients With Stage II Melanoma: The MIA Calculator.

PURPOSE: Improvements in recurrence-free survival (RFS) were demonstrated in two recent randomized trials for patients with sentinel node (SN)-negative stage IIB or IIC melanoma receiving adjuvant systemic therapy (pembrolizumab/nivolumab). However, adverse events also occurred. Accurate individualized prognostic estimates of RFS and overall survival (OS) would allow patients to more accurately weigh the risks and benefits of adjuvant therapy. Since the current American Joint Committee on Cancer eighth edition (AJCC-8) melanoma staging system focuses on melanoma-specific survival, we developed a multivariable risk prediction calculator that provides estimates of 5- and 10-year RFS and OS for these patients. METHODS: Data were extracted from the Melanoma Institute Australia (MIA) database for patients diagnosed with stage II (clinical or pathological) melanoma (n = 3,220). Survival prediction models were developed using multivariable Cox regression analyses (MIA models) and externally validated twice using data sets from the United States and the Netherlands. Each model's performance was assessed using C-statistics and calibration plots and compared with Cox models on the basis of AJCC-8 staging (stage models). RESULTS: The 5-year and 10-year RFS C-statistics were 0.70 and 0.73 (MIA-model) versus 0.61 and 0.60 (stage-model), respectively. For OS, the 5-year and 10-year C-statistics were 0.71 and 0.75 (MIA-model) compared with 0.62 and 0.61 (stage-model), respectively. The MIA models were well calibrated and externally validated. CONCLUSION: The MIA models offer accurate and personalized estimates of both RFS and OS in patients with stage II melanoma even in the absence of pathological staging with SN biopsy. These models were robust on external validations and may be used in everyday practice both with (ideally) and without performing SN biopsy to identify high-risk patients for further management strategies. An online tool will be available at the MIA website (Risk Prediction Tools).

Deletion Xq27.3q28 in female patient with global developmental delays and skewed X-inactivation.

BACKGROUND: Global developmental delay and mental retardation are associated with X-linked disorders including Hunter syndrome (mucopolysaccharidosis type II) and Fragile X syndrome (FXS). Single nucleotide mutations in the iduronate 2-sulfatase (IDS) gene at Xq28 most commonly cause Hunter syndrome while a CGG expansion in the FMR1 gene at Xq27.3 is associated with Fragile X syndrome. Gene deletions of the Xq27-28 region are less frequently found in either condition with rare reports in females. Additionally, an association between Xq27-28 deletions and skewed X-inactivation of the normal X chromosome observed in previous studies suggested a primary role of the Xq27-28 region in X-inactivation. CASE PRESENTATION: We describe the clinical, molecular and biochemical evaluations of a four year-old female patient with global developmental delay and a hemizygous deletion of Xq27.3q28 (144,270,614-154,845,961 bp), a 10.6 Mb region that contains >100 genes including IDS and FMR1. A literature review revealed rare cases with similar deletions that included IDS and FMR1 in females with developmental delay, variable features of Hunter syndrome, and skewed X-inactivation of the normal X chromosome. In contrast, our patient exhibited skewed X-inactivation of the deleted X chromosome and tested negative for Hunter syndrome. CONCLUSIONS: This is a report of a female with a 10.6 Mb Xq27-28 deletion with skewed inactivation of the deleted X chromosome. Contrary to previous reports, our observations do not support a primary role of the Xq27-28 region in X-inactivation. A review of the genes in the deletion region revealed several potential genes that may contribute to the patient's developmental delays, and sequencing of the active X chromosome may provide insight into the etiology of this clinical presentation.

Obesity Is Associated with Altered Tumor Metabolism in Metastatic Melanoma.

PURPOSE: Overweight/obese (OW/OB) patients with metastatic melanoma unexpectedly have improved outcomes with immune checkpoint inhibitors (ICI) and BRAF-targeted therapies. The mechanism(s) underlying this association remain unclear, thus we assessed the integrated molecular, metabolic, and immune profile of tumors, as well as gut microbiome features, for associations with patient body mass index (BMI). EXPERIMENTAL DESIGN: Associations between BMI [normal (NL < 25) or OW/OB (BMI ≥ 25)] and tumor or microbiome characteristics were examined in specimens from 782 patients with metastatic melanoma across 7 cohorts. DNA associations were evaluated in The Cancer Genome Atlas cohort. RNA sequencing from 4 cohorts (n = 357) was batch corrected and gene set enrichment analysis (GSEA) by BMI category was performed. Metabolic profiling was conducted in a subset of patients (x = 36) by LC/MS, and in flow-sorted melanoma tumor cells (x = 37) and patient-derived melanoma cell lines (x = 17) using the Seahorse XF assay. Gut microbiome features were examined in an independent cohort (n = 371). RESULTS: DNA mutations and copy number variations were not associated with BMI. GSEA demonstrated that tumors from OW/OB patients were metabolically quiescent, with downregulation of oxidative phosphorylation and multiple other metabolic pathways. Direct metabolite analysis and functional metabolic profiling confirmed decreased central carbon metabolism in OW/OB metastatic melanoma tumors and patient-derived cell lines. The overall structure, diversity, and taxonomy of the fecal microbiome did not differ by BMI. CONCLUSIONS: These findings suggest that the host metabolic phenotype influences melanoma metabolism and provide insight into the improved outcomes observed in OW/OB patients with metastatic melanoma treated with ICIs and targeted therapies. See related commentary by Smalley, p. 5.

Validation of the Use of Dried Blood Samples for the Detection of Toxoplasma gondii Antibodies in Stray Cats (Felis s. catus).

If validated beforehand, the analysis of dried blood on blotting paper (BP samples) is very useful for monitoring free-ranging animals. We aimed to validate this method for the detection of antibodies against Toxoplasma gondii in stray cats. We used the modified agglutination test (MAT) in 199 sample pairs of sera and BP samples from 54, 39, 56, and 50 cats trapped during four periods in five dairy farms. Screening was at 1:6, 1:12, and 1:24 dilutions. The cut-off value was at MAT titre ≥ 24, but MAT titre ≥ 12 was also considered for BP samples that often have a higher dilution level. Depending on the period, sample type, and cut-off value, sensitivity of the analysis of the BP sample vs. serum varied from 87.1% to 100% and specificity ranged from 72.22% to 100%. The concordance values and Kappa coefficient showed a substantial to excellent agreement between the results of the two methods, whatever the cut-off value. These findings quantifiably validate the use of MAT on BP samples for the detection of antibodies to T. gondii in stray cats, but we recommend expressing results from BP samples with several cut-off values as the MAT titres tend to be lower than those of sera.

Identification of MicroRNA-mRNA Networks in Melanoma and Their Association with PD-1 Checkpoint Blockade Outcomes.

Metastatic melanoma is a deadly malignancy with poor outcomes historically. Immuno-oncology (IO) agents, targeting immune checkpoint molecules such as cytotoxic T-lymphocyte associated protein-4 (CTLA-4) and programmed cell death-1 (PD-1), have revolutionized melanoma treatment and outcomes, achieving significant response rates and remarkable long-term survival. Despite these vast improvements, roughly half of melanoma patients do not achieve long-term clinical benefit from IO therapies and there is an urgent need to understand and mitigate mechanisms of resistance. MicroRNAs are key post-transcriptional regulators of gene expression that regulate many aspects of cancer biology, including immune evasion. We used network analysis to define two core microRNA-mRNA networks in melanoma tissues and cell lines corresponding to 'MITF-low' and 'Keratin' transcriptomic subsets of melanoma. We then evaluated expression of these core microRNAs in pre-PD-1-inhibitor-treated melanoma patients and observed that higher expression of miR-100-5p and miR-125b-5p were associated with significantly improved overall survival. These findings suggest that miR-100-5p and 125b-5p are potential markers of response to PD-1 inhibitors, and further evaluation of these microRNA-mRNA interactions may yield further insight into melanoma resistance to PD-1 inhibitors.

Gut microbiota signatures are associated with toxicity to combined CTLA-4 and PD-1 blockade.

Treatment with combined immune checkpoint blockade (CICB) targeting CTLA-4 and PD-1 is associated with clinical benefit across tumor types, but also a high rate of immune-related adverse events. Insights into biomarkers and mechanisms of response and toxicity to CICB are needed. To address this, we profiled the blood, tumor and gut microbiome of 77 patients with advanced melanoma treated with CICB, with a high rate of any ≥grade 3 immune-related adverse events (49%) with parallel studies in pre-clinical models. Tumor-associated immune and genomic biomarkers of response to CICB were similar to those identified for ICB monotherapy, and toxicity from CICB was associated with a more diverse peripheral T-cell repertoire. Profiling of gut microbiota demonstrated a significantly higher abundance of Bacteroides intestinalis in patients with toxicity, with upregulation of mucosal IL-1ß in patient samples of colitis and in pre-clinical models. Together, these data offer potential new therapeutic angles for targeting toxicity to CICB.

Dietary fiber and probiotics influence the gut microbiome and melanoma immunotherapy response.

Gut bacteria modulate the response to immune checkpoint blockade (ICB) treatment in cancer, but the effect of diet and supplements on this interaction is not well studied. We assessed fecal microbiota profiles, dietary habits, and commercially available probiotic supplement use in melanoma patients and performed parallel preclinical studies. Higher dietary fiber was associated with significantly improved progression-free survival in 128 patients on ICB, with the most pronounced benefit observed in patients with sufficient dietary fiber intake and no probiotic use. Findings were recapitulated in preclinical models, which demonstrated impaired treatment response to anti­programmed cell death 1 (anti­PD-1)­based therapy in mice receiving a low-fiber diet or probiotics, with a lower frequency of interferon-γ­positive cytotoxic T cells in the tumor microenvironment. Together, these data have clinical implications for patients receiving ICB for cancer.

Elevated exhaled carbon monoxide concentration in hemoglobinopathies and its relation to red blood cell transfusion therapy.

In this study, the authors examined a possible role of measurements of end-tidal carbon monoxide (CO), corrected for inhaled CO (ETCOc), as a noninvasive screening tool for hemoglobinopathies and as an indicator for when transfusions would be required in patients receiving chronic transfusions. ETCOc measurements were obtained in subjects with sickle cell disease (n = 18), thalassemia (n = 21), and healthy controls (n = 62). ETCOc values less than 3 parts per million (ppm) yielded a positive predictive value of 93% and negative predictive value of 94% in identifying hemoglobinopathies. Subsequently, 7 subjects with thalassemia had laboratory parameters and ETCOc measured over 2 transfusion cycles. ETCOc values were 4.90 +/- 0.32 ppm (mean +/- SD), with 89% of values being above normal (>or=3 ppm). Pretransfusion ETCOc levels significantly correlated with pretransfusion reticulocyte count (r = .96, P <.001), but not with pretransfusion hemoglobin (r = .44, P = .16) or pretransfusion soluble transferrin receptors (sTfR, r = .52, P = .10). In conclusion, we found that patients with hemoglobinopathies have ETCOc values above the range for healthy controls and ETCOc measurements can be used as an adjunct to hemoglobin measurements to determine the proper timing of transfusions.

Integration and Standardization of Clinical Nurse Specialists in a Multihospital System: Exemplars in Practice.

PURPOSES/OBJECTIVES: In 2013, our multihospital system began the process to integrate and standardize clinical nurse specialist (CNS) practice. The goal was to standardize work and to increase collaboration as part of one system. DESCRIPTION OF THE PROJECT/PROGRAM: An overall job description was established to provide a framework inclusive of the broad areas of practice. Clinical nurse specialists were positioned to support medical-surgical, critical care, or women and children's services offered at community-based hospitals. Main campus and community-based CNSs led significant system integration efforts such as the standardization of nursing policies and procedures across the health system. System CNSs were created to address the needs of specialties common to all hospitals. As an example, a system CNS collaborated with the main campus and community-based CNSs to improve the delirium screening process. OUTCOME: Clinical nurse specialists across the system have been integrated into a single team and report to 1 central director. Efforts to leverage expertise included the creation of a CNS-led practice council, increased communication via regular departmental meetings, and the sharing of resources using electronic platforms. There is now a CNS at hospitals that previously did not have one. The group values the structure and opportunities it provides as evidenced by favorable engagement surveys. CONCLUSION: Our integration efforts improved collaboration and could be modified to benefit other care settings.

Validation of a Novel Cutaneous Neoplasm Diagnostic Self-Efficacy Instrument (CNDSEI) for Evaluating User-Perceived Confidence With Dermoscopy.

BACKGROUND: Accurate medical image interpretation is an essential proficiency for multiple medical specialties, including dermatologists and primary care providers. A dermatoscope, a ×10-×20 magnifying lens paired with a light source, enables enhanced visualization of skin cancer structures beyond standard visual inspection. Skilled interpretation of dermoscopic images improves diagnostic accuracy for skin cancer. OBJECTIVE: Design and validation of Cutaneous Neoplasm Diagnostic Self-Efficacy Instrument (CNDSEI)-a new tool to assess dermatology residents' confidence in dermoscopic diagnosis of skin tumors. METHODS: In the 2018-2019 academic year, the authors administered the CNDSEI and the Long Dermoscopy Assessment (LDA), to measure dermoscopic image interpretation accuracy, to residents in 9 dermatology residency programs prior to dermoscopy educational intervention exposure. The authors conducted CNDSEI item analysis with inspection of response distribution histograms, assessed internal reliability using Cronbach's coefficient alpha (α) and construct validity by comparing baseline CNDSEI and LDA results for corresponding lesions with one-way analysis of variance (ANOVA). RESULTS: At baseline, residents respectively demonstrated significantly higher and lower CNDSEI scores for correctly and incorrectly diagnosed lesions on the LDA (P = 0.001). The internal consistency reliability of CNDSEI responses for the majority (13/15) of the lesion types was excellent (α ≥ 0.9) or good (0.8≥ α <0.9). CONCLUSIONS: The CNDSEI pilot established that the tool reliably measures user dermoscopic image interpretation confidence and that self-efficacy correlates with diagnostic accuracy. Precise alignment of medical image diagnostic performance and the self-efficacy instrument content offers opportunity for construct validation of novel medical image interpretation self-efficacy instruments.

Calcium-sensing receptor autoantibody-mediated hypoparathyroidism associated with immune checkpoint inhibitor therapy: diagnosis and long-term follow-up.

BACKGROUND: Immune checkpoint inhibitors (ICIs) have produced significant survival benefit across many tumor types. However, immune-related adverse events are common including autoimmune responses against different endocrine organs. Here, a case of ICI-mediated hypoparathyroidism focusing on long-term follow-up and insights into its etiology is presented. CASE AND METHODS: A 73-year-old man developed severe symptomatic hypocalcemia after the initiation of ipilimumab and nivolumab for the treatment of metastatic melanoma. Hypoparathyroidism was diagnosed with undetectable intact parathyroid hormone (PTH). Immunoprecipitation assays, ELISAs, and cell-based functional assays were used to test the patient for antibodies against the calcium-sensing receptor (CaSR). NACHT leucine-rich repeat protein 5 (NALP5) and cytokine antibodies were measured in radioligand binding assays and ELISAs, respectively. RESULTS: The patient's symptoms improved with aggressive calcium and vitamin D supplementation. At 3 years and 3 months since the diagnosis of hypoparathyroidism, PTH was still inappropriately low at 7.6 pg/mL, and attempted discontinuation of calcium and calcitriol resulted in recurrent symptomatic hypocalcemia. Analysis for an autoimmune etiology of the patient's hypoparathyroidism indicated that CaSR antibodies were negative before treatment and detected at multiple time points afterwards, and corresponded to the patient's clinical course of hypoparathyroidism. CaSR antibodies purified from the patient's serum activated the human CaSR. The patient was seronegative for NALP5 and cytokine antibodies, indicating that their hypoparathyroidism was not a manifestation of autoimmune polyendocrine syndrome type 1. CONCLUSION: The etiology of hypocalcemia is likely autoimmune hypoparathyroidism caused by the development of CaSR-activating antibodies that might prevent PTH release from the parathyroid.

Homozygous 15q13.3 microdeletion in a child with hypotonia and impaired vision: A new report and review of the literature.

Although there are numerous reports of heterozygous 15q13.3 microdeletion, homozygous 15q13.3 microdeletion is rare. We report a new patient with homozygous microdeletion of 15q13.2q13.3 and review the previous literature reports. Common clinical features include encephalopathy, hypotonia, developmental delay, cortical vision impairment, optic nerve abnormality, epilepsy, and abnormal electroencephalogram (EEG) findings.

Pattern of latrine use by domestic cats on dairy farms and the implications for Toxoplasma gondii transmission.

Toxoplasma gondii is the parasite responsible for toxoplasmosis, a highly prevalent zoonosis that affects humans and warm-blooded animals. Faeces of infected cats can contain millions of T. gondii oocysts, which remain infectious in the environment for months. Sites repeatedly used by cats for defecation ('latrines') are recognised as hotspots of T. gondii soil contamination, but this contamination varies from one latrine to another. To understand this spatial heterogeneity, camera traps were deployed in 39 cat latrines on three dairy farms with high-density cat populations and programmed to record visits during sixteen 10-day sessions, rotating between three farms over a period of a year. Generalized Linear Mixed Models were used to test the effects of cat sexual maturity, latrine location and season on the number of cat faeces deposited and on the number of cats defecating per latrine, as determined from the analysis of 41,282 video recordings. Sexually immature cats defecated 6.60-fold (95% CI = [2.87-15.25]) more often in latrines located close to a feeding site than in other latrines. This pattern was also observed for mature males (odds ratio [OR] = 9.42, 95% CI = [3.29-26.91]), especially during winter, but not for mature females (OR = 1.77, 95% CI = [0.80-3.94]). The number of defecating cats was also 2.67-fold (95% CI = [1.66-4.30], P < 0.001) higher in latrines located close to a feeding point than in those located far from it, regardless of cat category and season. Visits by intermediate T. gondii hosts (micromammals, birds and others) were also recorded. Out of the 39 latrines, 30 (76.92%) were visited by at least one intermediate host during the study period, and some latrines were highly frequented (up to 8.74 visits/day on average). These results provide evidence that the location of food resources in dairy farms influences the latrine use pattern by cats. Highly frequented latrines can be of high risk of T. gondii infection for definitive and intermediate hosts.

Variable clinical features and genotype-phenotype correlations in 18 patients with late-onset Pompe disease.

BACKGROUND: Pompe disease is a lysosomal storage disorder caused by the deficiency of enzyme acid alpha-glucosidase (GAA) which results in accumulation of glycogen, particularly in the skeletal, cardiac, and smooth muscles. The late-onset form with symptoms presenting in childhood through adulthood, is characterized by proximal muscle weakness, respiratory insufficiency, and unlike the infantile-onset form often with no cardiac involvement. METHODS: We report our experience with 18 adult patients (14 males/4 females) with Pompe disease, several of whom had unique findings and novel pathogenic variants. Patients ranged in ages from 22-74 years (mean 53.7 years) and were diagnosed at an age range of 11-65 years (mean 43.6 years), often after a history of progressive muscle disease of several years' duration. All 18 patients were treated with alglucosidase alfa (Lumizyme) and their response to treatment was monitored by measurements of their pulmonary function and muscle weakness, six-minute walk test (6MWT), and other functional studies. RESULTS: Genetic sequencing revealed that 16 out of 18 individuals had the common c.-32-13T>G splicing variant, and six patients, including two sibships had four novel pathogenic variants: c.1594G>A, c.2655_2656delCG, c.1951-1952delGGinsT, and c.1134C>G. A male with the c.1594G>A variant developed an intracerebral aneurysm at the age of 43 years treated with surgery. Two siblings with the c.2655_2656delCG developed very high antibody titers, one of whom developed a severe infusion reaction. Other clinical features included BiPAP requirement in twelve, tinnitus in seven, scoliosis in five, cardiomyopathy in three, one individual was diagnosed with a cerebral aneurysm who underwent successful Penumbra coil placement, and another individual was diagnosed with both Graves' disease and testicular cancer. CONCLUSIONS: Our study illustrates significant variability in the range of clinical features, and the variable clinical response to enzyme replacement therapy. It also alerts us to the importance of careful monitoring and early management of complications. Possible genotype-phenotype associations with the novel mutations identified may emerge with larger studies.