The Development and Implementation of an Evidence-Based Tumescent Liposuction Protocol, Online Educational Course for Perioperative Staff, and Discharge Instructions: A Quality Improvement Project.

PURPOSE: The purpose of this quality improvement project was to improve perioperative management of patients undergoing tumescent liposuction (TL) through the development and implementation of a perioperative evidence-based protocol, educational course for perioperative staff, and patient discharge instructions. DESIGN: The TL protocol was validated using the modified Delphi process. The educational course and discharge instructions used a pre and postimplementation design. METHODS: An evidence-based protocol, an educational course for perioperative staff, and readable discharge instructions for patients undergoing TL were developed in accordance with best practice guidelines. The protocol was validated by subject matter experts at the facility and submitted for adoption. The evidence-based educational course was implemented, and the effectiveness of the course was evaluated for improving providers' knowledge and self-confidence. The evidence-based discharge instructions were implemented and evaluated for patient satisfaction and readability. FINDINGS: Three items were removed from the protocol, 2 items were modified, and 25 items were accepted with no change from modified Delphi analysis. Provider knowledge scores improved from 85.7% ± 16.18 to 97.1% ± 4.88; however, this was not statistically significant (P = .066). There was a trend toward improved confidence scores (P = .180). Overall patient satisfaction scores slightly improved postimplementation; results were not statistically significant (P > .05). CONCLUSIONS: All three phases of perioperative care in patients receiving TL were evaluated, reflecting best practice guidelines and successful adoption. There was no statistically significant improvement in provider knowledge, provider self-confidence, or patient satisfaction. A small sample size was a significant limiting factor.

Large-gap peripheral nerve repair using xenogeneic transplants in rhesus macaques.

Surgical intervention is required to successfully treat severe, large-gap (≥4 cm) peripheral nerve injuries. However, all existing treatments have shortcomings and an alternative to the use of autologous nerves is needed. Human and porcine nerves are physiologically similar, with comparable dimensions and architecture, presence and distribution of Schwann cells, and conserved features of the extracellular matrix (ECM). We report the repair of fully transected radial nerves in 10 Rhesus Macaques using viable, whole sciatic nerve from genetically engineered (GalT-KO), designated pathogen free (DPF) porcine donors. This resulted in the regeneration of the transected nerve, and importantly, recovery of wrist extension function, distal muscle reinnervation, and recovery of nerve conduction velocities and compound muscle action potentials similar to autologous controls. We also demonstrate the absence of immune rejection, systemic porcine cell migration, and detectable residual porcine material. Our preliminary findings support the safety and efficacy of viable porcine nerve transplants, suggest the interchangeable therapeutic use of cross-species cells, and highlight the broader clinical potential of xenotransplantation.

Small molecules inhibitors of the heterogeneous ribonuclear protein A18 (hnRNP A18): a regulator of protein translation and an immune checkpoint.

We have identified chemical probes that simultaneously inhibit cancer cell progression and an immune checkpoint. Using the computational Site Identification by Ligand Competitive Saturation (SILCS) technology, structural biology and cell-based assays, we identify small molecules that directly and selectively bind to the RNA Recognition Motif (RRM) of hnRNP A18, a regulator of protein translation in cancer cells. hnRNP A18 recognizes a specific RNA signature motif in the 3'UTR of transcripts associated with cancer cell progression (Trx, VEGF, RPA) and, as shown here, a tumor immune checkpoint (CTLA-4). Post-transcriptional regulation of immune checkpoints is a potential therapeutic strategy that remains to be exploited. The probes target hnRNP A18 RRM in vitro and in cells as evaluated by cellular target engagement. As single agents, the probes specifically disrupt hnRNP A18-RNA interactions, downregulate Trx and CTLA-4 protein levels and inhibit proliferation of several cancer cell lines without affecting the viability of normal epithelial cells. These first-in-class chemical probes will greatly facilitate the elucidation of the underexplored biological function of RNA Binding Proteins (RBPs) in cancer cells, including their effects on proliferation and immune checkpoint activation.

First-Person Point-of-View Instructional Video on Lumbar Puncture Procedure.

OBJECTIVES: Tutorial videos filmed from a first-person point of view (FP-POV) are generally well received. Pediatric residents are expected to be competent in performing the lumbar puncture (LP). The educational effectiveness of a FP-POV in lumbar puncture procedure training for resident physicians has yet to be evaluated. We compared a FPPOV LP video with a standard in-person demonstration of the LP. METHODS: We designed an assigned cohort study to compare a FP-POV procedural instructional video of a simulated pediatric LP to the standard in-person procedure demonstration.After the intervention, residents completed an LP observed by one of two blinded reviewers who assessed the procedure using a modified, published assessment tool.Participants completed preintervention and postintervention surveys to rate self-confidence and usefulness of the FP-POV educational method. The data was analyzed using a Wilcoxon Rank sum test. z Scores were calculated on the raw assessment scores. RESULTS: Eighteen first year pediatric residents participated, nine in each group. The median modified assessment tool score was 17 in the FP-POV group (min, 14; max, 17; IQR:, 1.5) and 14 in the standard demonstration group (min, 6; max, 17; IQR, 4.5), with the higher score being more successful. There was a statistical difference between the assessment scores between the 2 groups (z score = 2.18, P = 0.04). Postintervention survey data demonstrated relative satisfaction with the FPPOV educational method. CONCLUSIONS: This study supports the educational effectiveness of a FP-POV procedure tutorial.Future studies with a larger sample size are needed.

An Energy-Efficient T-Based Routing Topology for Target Tracking in Battery Operated Mobile Wireless Sensor Networks.

Real-time smart applications are now possible because to developments in communication and sensor technology. Wireless sensor networks (WSNs) are used to collect data from specific disaster sites, such as fire events, gas leaks, land mines, earthquake, landslides, etc., where it is necessary to know the exact location of the detected information to safely rescue the people. For instance, the detection and disposal of explosive materials is a difficult task because land mines consistently threaten human life. Here, the T-based Routing Topology (TRT) is suggested to gather data from sensors (metal detectors, Ground Penetrating Radars (GPR), Infra-Red sensors, etc.), Global Positioning System (GPS), and cameras in land mine-affected areas. Buried explosive materials can be found and located with high accuracy. Additionally, it will be simpler to eliminate bombs and reduce threats to humans. The efficiency of the suggested data collection method is evaluated using Network Simulator-2 (NS-2). Also, the proposed T-based routing topology requires a minimal number of nodes to cover the entire searching area and establish effective communication. In contrast, the number of nodes participating in the sensing area grows, as the depth of the tree increases in the existing tree topology-based data gathering. And for cluster topology, the number of nodes deployment depends on the transmission range of the sensor nodes.

Tumor necrosis factor inhibitor (TNFi) persistence and reasons for discontinuation in a predominantly male cohort with axial spondyloarthritis.

Although tumor necrosis factor inhibitors (TNFi) have favorably altered the treatment landscape for patients with axial spondyloarthritis (axSpA), there is limited data regarding TNFi persistence and reasons for discontinuation. This is an observational time-to-event study utilizing data collected for a prospective multiple-disease registry of US Veterans with axSpA treated with TNFi therapies and recruited over a 10 year period. Clinical, serological, and comorbid parameters were collected. Corporate Data Warehouse Pharmacy files provided courses of the 5 TNFi agents, and response to treatment was documented. Individual TNFi persistence was established utilizing univariate and multivariate Cox proportional models, and reasons for discontinuation were obtained by physician chart review. Two-hundred and fifty-five axSpA patients received 731 TNFi courses. A majority of patients (84.3%) had TNFi persistence at 12 months; 63.5% and 47.1% at 24 and 36 months, respectively. Compared to adalimumab, infliximab demonstrated greater persistence, certolizumab the least. Age, smoking status, BMI, comorbidity burden, inflammatory markers and HLA-B27 did not predict TNFi persistence or discontinuation. Stroke and peripheral arterial disease increased the probability of TNFi discontinuation. Secondary non-response (SNR) was the most common reason for discontinuation (46% of all courses); non-adherence (6%) and clinical remission (2%) were uncommon. Pain score at enrollment, myocardial infarction, African American race and inflammatory bowel disease (IBD) predicted TNFi response. While initial persistence of TNFi treatment was high, a large proportion of the patients discontinued initial TNFi therapy by 3 years, primarily due to loss of efficacy. While further research identifying potential predictors of TNFi discontinuation in axSpA is warranted, access to alternate disease-modifying therapies is needed.

Effects of caregiver counselling on medication persistence and adherence in patients with dementia at a pharmacist-managed clinic: A pilot study.

WHAT IS KNOWN AND OBJECTIVE: Low treatment persistence and adherence in patients with dementia results in a rapid loss of disease control. This pilot study evaluated the impact of pharmacist-provided caregiver counselling on treatment persistence, adherence, quality of life (QoL) in patients with dementia, as well as caregiver's knowledge of dementia, and caregiver burden. METHODS: This prospective, randomized controlled study was performed at a hospital-based pharmacist-managed clinic from December 2017 to December 2019. Patients with mild-to-moderate Alzheimer's disease (AD), initiating cholinesterase inhibitors within 3 months, and coming with their caregivers were included and randomized 1:1 to intervention or control group. The intervention group received pharmacist counselling and education sheets about AD, whereas the control group only received standard of care. Patients' treatment persistence and adherence were assessed at months 3, 6, 9, and 12; QoL, and caregiver burden were assessed at baseline and month 12. Caregiver's knowledge of dementia was assessed at baseline and 2 weeks after counselling in the intervention group. Nonparametric statistics and generalized estimating equation models were used for statistical analysis. RESULTS AND DISCUSSION: A total of 40 patients and 40 caregivers were included, with 20 pairs for each group. One-year medication persistence (16/20 vs. 16/20) and adherence rates (87%-99%) were high in both groups without significant differences. Dementia knowledge scores improved significantly after counselling in the intervention group (77.5 vs. 95.8, p < 0.01). Although the change of caregiver burden was non-significant between groups, the score decreased in the intervention group (-0.89; p = 0.78) but increased in the control group (+6.01; p = 0.07). WHAT IS NEW AND CONCLUSION: In this pilot study, pharmacist's counselling for patients with dementia and their caregivers is feasible and can enhance caregiver knowledge of dementia. Further study with larger scale is needed to confirm the impact on these outcomes.

Medications Without Borders: Themes in Caregiver Administration of Imported Medications in Pediatrics.

OBJECTIVE: This study aimed to identify motivating factors in why parents administer imported medications to their children. METHODS: In this qualitative study, we enrolled caregivers of patients younger than 18 years who presented for care at a pediatric emergency department. The study team conducted face-to-face interviews with caregivers in the emergency department and used a semistructured question guide to probe for themes regarding the use of imported medications in children. Interviews were recorded, transcribed, translated if necessary, and coded. We applied grounded theory methodology to assess for themes and adapted the Andersen model of health care utilization to provide a framework for the identified themes. RESULTS: We completed 30 interviews, 9 of which were conducted in Spanish. Themes surrounding imported medication usage were categorized into predisposing, enabling, and need factors. Predisposing factors included perception that an ill child needs medication to get better, perception of medication quality, and past experiences with medications. Enabling factors included proximity to foreign countries, cost, limited access to primary care, and convenience of obtaining medications. Need factors included utilization of foreign medications for a "simple illness" and utilization of foreign care for a "second opinion." CONCLUSIONS: Our study used qualitative methodology to gain important insights into the caregiver experience of a diverse patient population. We identify themes not previously published in the medication importation literature. These concepts can provide insights in educational strategies aimed at mitigating the potential dangers of imported medication use in pediatrics.

A qualitative study on the development of pharmacist-managed clinics in Taiwan.

WHAT IS KNOWN AND OBJECTIVE: Pharmacist-managed clinics (PMCs) are established to solve drug-related problems and enhance the quality of care of ambulatory patients. Although the benefits of such services have been demonstrated, little is known about PMC operations, especially outside the United States. The aim of this study was to explore how PMCs were established and to discuss implementation issues of PMCs in Taiwan. METHODS: A purposive sample of pharmacists, pharmacy administrators and physicians involved with PMCs was recruited from hospitals of varying scales across Taiwan. Semi-structured, individual interviews were conducted to understand the perceptions of the clinical service of PMCs. Interviews were transcribed verbatim and analysed by thematic analysis to find underlying themes. RESULTS: A total of 12 pharmacists, 5 pharmacy administrators and 3 physicians from 8 institutions were interviewed. Pharmacists spent 4 to 20 h per week at PMCs, and the practice experiences of PMC ranged from 1 to 6 years. PMCs have been provided in these institutions for 4 to 11 years with an average volume of 28 h and 25 patient visits weekly. Study participants described influential factors in establishing PMCs, including clinical expertise, attitude towards patient care and trust building with collaborating physicians. Operational concerns in implementing PMCs included role clarifications, manpower shortage, inadequate advanced training or certification, regulatory issues and a lack of service promotion. WHAT IS NEW AND CONCLUSION: This research broadens the understanding of operating PMC services and reveals key requirements and concerns regarding the care model, which can be useful for other countries. Resolving perceived barriers and collecting other stakeholders' perspectives may reinforce the integration of PMCs into patient care in the future.

Immunological response in cynomolgus macaques to porcine α-1,3 galactosyltransferase knockout viable skin xenotransplants-A pre-clinical study.

BACKGROUND: Allogeneic skin recovered from human deceased donors (HDD) has been a mainstay interim treatment for severe burns, but unfortunately risk of infectious disease and availability limitations exist. Genetically engineered ɑ-1,3 galactosyltransferase knockout (GalT-KO) porcine source animals for viable skin xenotransplants may provide a promising clinical alternative. METHODS: Four cynomolgus macaque recipients received full-thickness surgical wounds to model the defects arising from excision of full-thickness burn injury and were treated with biologically active skin xenotransplants derived from GalT-KO, Designated Pathogen Free (DPF) miniature swine. Evaluations were conducted for safety, tolerability, and recipient immunological response. RESULTS: All skin xenotransplants demonstrated prolonged survival, vascularity, and persistent dermal adhesion until the study endpoint at post-operative day 30. No adverse outcomes were observed during the study. Varying levels of epidermolysis coincided with histologic detection of CD4+ and CD8+ T cells, and other cellular infiltrates in the epidermis. Recipient sera IgM and IgG demonstrated significant antibody immune response to non-α-1,3-galactose porcine xenoantigens. Separately, specific wound healing mediators were quantified. Neither porcine cell migration nor PERV were detected in circulation or any visceral organs. CONCLUSIONS: These results provide a detailed analysis of vital skin xenotransplants utilizing a non-human primate model to predict the anticipated immunological response of human patients. The lack of adverse rejection even in the presence of elevated Ig indicates this is a prospective therapeutic option. The findings reported here directly supported regulatory clearance for a first-in-man, Phase I xenotransplantation clinical trial.

Preoperative Opioid Use Predicts Prolonged Postoperative Opioid Use and Inferior Patient Outcomes Following Anterior Cruciate Ligament Reconstruction.

PURPOSE: (1) To determine patient factors associated with prolonged opioid use following anterior cruciate ligament reconstruction (ACLR) and (2) to evaluate the influence of preoperative opioid use on patient-reported outcomes. METHODS: Patients who underwent ACLR and used opioids before the perioperative period, which was defined as the window 30 days before 15 days following the index surgery, were designated as preoperative opioid users. Patients who used opioids only in the perioperative period or post-operative period were designated as opioid-naïve. Predictors of opioid use at 6 and 12 months postoperatively and associations between preoperative opioid use and patient outcomes were assessed. RESULTS: After institutional review board approval, we identified 253 patients (225 opioid-naïve and 28 opioid users ) who underwent ACLR from 2014 to 2018 at a single institution and had one year follow up (median: 11.6 months; interquartile range [8.9-14.3]). Patients with a history of preoperative opioid use (odds ratio [OR] 3.63, P = .034), greater preoperative visual analog scale pain scores (OR 1.32, 95% CI 1.04-1.67; P = .003), and greater body mass index (OR 1.09, P = .018) were significantly more likely to be taking opioids at 6 months postoperatively. Patients with a perioperative opioid intake of greater than 513 oral morphine equivalents were significantly more likely to continue taking opioids at the 6 month (OR 3.17, P = .024) and the 1 year (OR 3.34, P = .048) postoperative time points. Patients with preoperative opioid use were significantly less likely to achieve the patient acceptable symptomatic state (PASS) on the International Knee Documentation Committee, Knee Injury and Osteoarthritis Outcome Score (KOOS) Sport, KOOS Joint Replacement, KOOS Pain, KOOS Symptoms, KOOS Quality of Life, and KOOS Activities of Daily Living. CONCLUSIONS: Preoperative opioid use, body mass index >30, and greater visual analog scale pain scores were predictors of continued opioid use at 6 months postoperatively. Preoperative opioid users were more likely to continue taking opioids, demonstrate significantly worse patient reported outcomes at baseline and 1-year postoperatively, and were less likely to achieve patient acceptable symptomatic state. LEVEL OF EVIDENCE: Level III, Retrospective Cohort Study.

Influence of mental health on postoperative outcomes in patients following biceps tenodesis.

PURPOSE: To evaluate the relationship between preoperative mental health measured by the Short-Form 12 health survey mental component score and outcomes after isolated biceps tenodesis. METHODS: The American Shoulder and Elbow Surgeons form (ASES), Single Assessment Numeric Evaluation (SANE), Constant-Murley score (CMS), and visual analog scale (VAS) for pain were administered preoperatively and at 6 and 12 months postoperatively to consecutive patients undergoing isolated biceps tenodesis between 2014 and 2018. Minimal clinically important difference, substantial clinical benefit (SCB), patient-acceptable symptom state (PASS), and rates of achievement were calculated. Patients were stratified by mental health status based on preoperative scores on the Short-Form 12 health survey mental component score. Multivariate logistic regression was performed to evaluate preoperative mental health status on achievement of minimal clinically important difference, SCB, and PASS. RESULTS: Patients demonstrated significant improvements in all outcome measures (P < .001). Patients with depression reported inferior postoperative scores on all patient-reported outcome measures. Low preoperative mental health score significantly predicted reduced likelihood to achieve SCB (odds ratio [OR]: 0.38, 95% confidence interval [CI]: 0.17-0.81, P = .01) and PASS (OR: 0.28, 95% CI: 0.12-0.65, P = .003) on the ASES form, SANE (OR: 0.24, 95% CI: 0.10-0.61, P = .003), CMS (OR: 0.25, 95% CI: 0.08-0.77, P = .016), and VAS pain (OR: 0.01, 95% CI: 0.00-0.31, P = .008). CONCLUSION: Patients with depression reported inferior scores on all postoperative patient-reported outcome measures and demonstrated lower odds of achieving the SCB and PASS on the ASES form and PASS on the SANE, CMS, and VAS pain, compared with nondepressed patients.

Predictors of Successful HIV Care Re-engagement Among Persons Poorly Engaged in HIV Care.

The Data to Care (D2C) strategy uses HIV surveillance data to identify persons living with HIV (PLWH) who are poorly engaged in care and offers assistance with care re-engagement. We evaluated HIV care re-engagement among PLWH in Seattle & King County, Washington after participation in a D2C program and determined whether variables available at the time of the D2C interview predicted subsequent re-engagement in care. We defined successful re-engagement as surveillance evidence of either continuous care engagement (≥ 2 CD4 counts or HIV RNA results ≥ 60 days apart) or viral suppression (≥ 1 HIV RNA < 200 copies/mL) in the year following the D2C interview. Predictor variables included client characteristics, beliefs about HIV care, and scores on psychosocial assessment scales. Half of participants successfully re-engaged in care. We did not find any significant predictors of re-engagement except viral suppression at the time of the D2C interview. Close follow-up is needed to identify which D2C participants need additional assistance re-engaging in care.

An investigation of the determinants for community pharmacists' positive image and the needs for community pharmacists' services in Taiwan.

OBJECTIVES: To examine the specific factors that the general public believes have an effect on the image of community pharmacists and also to identify community pharmacists' services that truly fulfill people's needs. METHODS: A convenient sample of 401 community pharmacy customers completed the questionnaire. RESULTS: When asked about the factors that help establish a positive image for a community pharmacist, 98.3% of the respondents reported accurate dispensing as the most important factor, followed by cordial attitude (95.5%), and wearing clothes showing pharmacist's license with a photo (94.6%). Among the services provided by community pharmacies, most people think that the most needed service is a consultation explaining drug-drug interactions (93.8%). Furthermore, 312 (77.8%) respondents indicated that there is a need for comprehensive pharmaceutical services. As for the amount that the respondents were willing to pay for such service, many (42.9%) chose 100 NT dollars (≈ 3USD). CONCLUSION: The results of this study showed that correct dispensing is the most important factor that helps establish a positive image of community pharmacists and that the most needed services were those that required pharmacists' professional competence. Moreover, nearly 80% of the respondents reported that they needed comprehensive pharmaceutical services and were willing to pay for it.

HS-SPME-GC-MS Analyses of Volatiles in Plant Populations-Quantitating Compound × Individual Matrix Effects.

Headspace solid-phase microextraction (HS-SPME) coupled to gas chromatography⁻mass spectrometry (GC-MS) is widely employed for volatile analyses of plants, including mapping populations used in plant breeding research. Studies often employ a single internal surrogate standard, even when multiple analytes are measured, with the assumption that any relative changes in matrix effects among individuals would be similar for all compounds, i.e., matrix effects do not show Compound × Individual interactions. We tested this assumption using individuals from two plant populations: an interspecific grape (Vitis spp.) mapping population (n = 140) and a tomato (Solanum spp.) recombinant inbred line (RIL) population (n = 148). Individual plants from the two populations were spiked with a cocktail of internal standards (n = 6, 9, respectively) prior to HS-SPME-GC-MS. Variation in the relative responses of internal standards indicated that Compound × Individual interactions exist but were different between the two populations. For the grape population, relative responses among pairs of internal standards varied considerably among individuals, with a maximum of 249% relative standard deviation (RSD) for the pair of [U13C]hexanal and [U13C]hexanol. However, in the tomato population, relative responses of internal standard pairs varied much less, with pairwise RSDs ranging from 8% to 56%. The approach described in this paper could be used to evaluate the suitability of using surrogate standards for HS-SPME-GC-MS studies in other plant populations.

Cognitive processes in spatial mapping: Evidence from a developmental spatial deficit.

We report a case study of an adolescent girl (N.K.Y.) with a developmental deficit affecting spatial processing. In a simple spatial mapping task, N.K.Y. shows a striking dissociation: She succeeds in one variant of the experiment in which the stimuli are objects, but struggles in a structurally identical task with people as stimuli. We present evidence that this dissociation stems from a tendency to automatically adopt the spatial perspective of other people, but not objects-a phenomenon also observed in neurotypical individuals. When adopting another person's perspective, N.K.Y. imagines herself in the other's position, representing the other's left and right as if it were her own. N.K.Y.'s deficit in relating left-right information to her own body then disrupts her performance. Our results shed light on the nature of N.K.Y.'s deficit as well as the cognitive operations involved in spatial perspective taking.

Development and validation of a Chinese medication literacy measure.

BACKGROUND: Despite the impact of medication literacy (ML) on patients' safe use of medications, existing instruments are mostly for general health literacy measurement or designed for specific disease populations, with few specifically designed for ML. OBJECTIVE: To develop and validate the first Chinese medication literacy measure (ChMLM). METHODS: The ChMLM was developed by a multidisciplinary and bilingual expert panel and subsequently pilot-tested. The final version had 17 questions in four sections: vocabulary, non-prescription drug, prescription drug and drug advertisement. Face-to-face interviews were administered in a convenience sample of adults with diverse sociodemographic characteristics. Internal consistency was assessed by Cronbach's alpha. Content validity was confirmed by the expert panel, and hypothesis testing was performed to assess construct validity. RESULTS: A total of 634 adults were interviewed. The mean (SD) total ChMLM score was 13.0 (2.8). The internal validity was acceptable (Cronbach's alpha=0.72). Nine of the ten a priori hypotheses were fulfilled. Younger age, higher income and higher education levels were significantly associated with a higher ChMLM score. Furthermore, higher scores on the ChMLM were associated with higher confidence or less difficulty in writing, reading, speaking and listening abilities in a health-care encounter. No association was found between ChMLM total scores and frequency of doctor's visits. CONCLUSION: The ChMLM is a valid and reliable ML measure. It may help pharmacists and other health-care providers to target patients and problem areas that need interventions with the ultimate goal of preventing medication errors and harm.

Next generation sequencing revealed DNA ligase IV deficiency in a "developmentally normal" patient with massive brain Epstein-Barr virus-positive diffuse large B-cell lymphoma.

INTRODUCTION: Here we present an unusual case of DNA ligase IV deficiency syndrome without dysmorphic facial findings and microcephaly complicated with Epstein-Barr virus-associated large B-cell lymphoma with the right lung involvement and a massive brain tumor lesion in a two-year-old female. METHODS: PID panel was used for sequencing 55 genes. Most genes have >98% exon coverage including splicing sites. LIG4 gene has 100% exon and splicing site coverage. This was used in Ion Torrent PGM system, the library kit was made by Agilent with Haloplex technology. The sequence analysis software was Alamut, direct sequencing of LIG4 gene was performed after NGS results. RESULT: We identified three heterozygous mutations in LIG4 gene c.2736+3delC and c.8 C>T (p.A3V) inherited from mother and c.26C>T (p.T9I) - from father after PID panel sequencing and some additional polymorphisms in ATM, NOD2 and NLRP3 genes. CONCLUSION: This case broadens the clinical spectrum of DNA ligase IV deficiency.

A Distributed Network for Intensive Longitudinal Monitoring in Metastatic Triple-Negative Breast Cancer.

Accelerating cancer research is expected to require new types of clinical trials. This report describes the Intensive Trial of OMics in Cancer (ITOMIC) and a participant with triple-negative breast cancer metastatic to bone, who had markedly elevated circulating tumor cells (CTCs) that were monitored 48 times over 9 months. A total of 32 researchers from 14 institutions were engaged in the patient's evaluation; 20 researchers had no prior involvement in patient care and 18 were recruited specifically for this patient. Whole-exome sequencing of 3 bone marrow samples demonstrated a novel ROS1 variant that was estimated to be present in most or all tumor cells. After an initial response to cisplatin, a hypothesis of crizotinib sensitivity was disproven. Leukapheresis followed by partial CTC enrichment allowed for the development of a differential high-throughput drug screen and demonstrated sensitivity to investigational BH3-mimetic inhibitors of BCL-2 that could not be tested in the patient because requests to the pharmaceutical sponsors were denied. The number and size of CTC clusters correlated with clinical status and eventually death. Focusing the expertise of a distributed network of investigators on an intensively monitored patient with cancer can generate high-resolution views of the natural history of cancer and suggest new opportunities for therapy. Optimization requires access to investigational drugs.

Evidence for feasibility of fetal trophoblastic cell-based noninvasive prenatal testing.

OBJECTIVE: The goal was to develop methods for detection of chromosomal and subchromosomal abnormalities in fetal cells in the mother's circulation at 10-16 weeks' gestation using analysis by array comparative genomic hybridization (CGH) and/or next-generation sequencing (NGS). METHOD: Nucleated cells from 30 mL of blood collected at 10-16 weeks' gestation were separated from red cells by density fractionation and then immunostained to identify cytokeratin positive and CD45 negative trophoblasts. Individual cells were picked and subjected to whole genome amplification, genotyping, and analysis by array CGH and NGS. RESULTS: Fetal cells were recovered from most samples as documented by Y chromosome PCR, short tandem repeat analysis, array CGH, and NGS including over 30 normal male cells, one 47,XXY cell from an affected fetus, one trisomy 18 cell from an affected fetus, nine cells from a trisomy 21 case, three normal cells and one trisomy 13 cell from a case with confined placental mosaicism, and two chromosome 15 deletion cells from a case known by CVS to have a 2.7 Mb de novo deletion. CONCLUSION: We believe that this is the first report of using array CGH and NGS whole genome sequencing to detect chromosomal abnormalities in fetal trophoblastic cells from maternal blood. © 2016 The Authors. Prenatal Diagnosis published by John Wiley & Sons, Ltd.