Validation of an LC-MS/MS assay for rapid and simultaneous quantification of 21 kinase inhibitors in human plasma and serum for therapeutic drug monitoring.

Kinase inhibitors have revolutionized cancer treatment in the past 25 years and currently form the cornerstone of many treatments. Due to the increasing evidence for therapeutic drug monitoring (TDM) of kinase inhibitors, the need is growing for new assays to rapidly evaluate kinase inhibitor plasma concentrations. In this study, we developed an LC-MS/MS assay for the rapid and simultaneous quantification of 21 kinase inhibitors. First, a literature search was conducted to ensure that the linear ranges of the analytes were in line with the reported therapeutic windows and/or TDM reference values. Subsequently, the assay was validated according to FDA and EMA guidelines for linearity, selectivity, carry-over, accuracy, precision, dilution integrity, matrix effect, recovery, and stability. The assay was fast, with a short run-time of 2 min per sample. Sample pre-treatment consisted of protein precipitation with methanol enriched with stable isotope-labeled internal standards (SIL-IS), and the mixture was vortexed and centrifuged before sample injection. Separation was achieved using a C18 column (3 µm,50 × 2.1 mm) with a gradient of two mobile phases (ammonium formate buffer pH 3.5 and acetonitrile). Analyte detection was conducted in positive ionization mode using selected reaction monitoring. The assay was accurate and precise in plasma as well as in serum. Extraction recovery ranged between 95.0% and 106.0%, and the matrix effect was 95.7%-105.2%. The stability of the analytes varied at room temperature and in refrigerated conditions. However, all drugs were found to be stable for 7 days in the autosampler. The clinical applicability of the analytical method (486 analyzed samples between 1 July 2022-1 July 2023) as well as external quality control testing results were evaluated. Taken together, the results demonstrate that the analytical method was validated and applicable for routine analyses in clinical practice.

Novel Diagnostic Imaging Approach for Patients With Spontaneous Coronary Artery Dissection: The Utility of 18 F-FDG PET Imaging.

ABSTRACT: Spontaneous coronary artery dissection (SCAD) is an underdiagnosed etiology of acute coronary syndrome in women. Accurate diagnosis remains challenging but is imperative for treatment and prevention. We show here the utility of 18 F-FDG PET imaging in SCAD diagnosis. We present 1 representative case of 4 women with suspected SCAD on coronary angiography from the EVACS (Evolocumab in Acute Coronary Syndromes) clinical trial. 18 F-FDG PET imaging showed acute inflammation in the distribution of the suspected dissected coronary artery identified on angiography. Localized myocardial inflammation identified on 18 F-FDG PET imaging can aid in diagnosing SCAD suspected on coronary angiography.

Reverse Total Shoulder Arthroplasty in Alkaptonuric Shoulder: Case Presentation, Review of Literature, and Technical Considerations.

Importance: Alkaptonuric shoulder arthropathy is a challenging clinical entity in arthroplasty. In this report, we describe an atypical presentation, technical considerations, a literature review, and some recommendations of significant benefits to shoulder surgeons. Objective: The author's objective in this report is to illustrate the deleterious metabolic effects of ochronosis on cartilage and the development of early arthritis. Design: This is a case report study, done in May 2021. Setting: Middle East, Jordan. Introduction: Alkaptonuria is a metabolic disease of amino acid metabolism that can affect multiple organ systems, including the musculoskeletal system. The musculoskeletal system manifestations usually involve the spine, knee, and, uncommonly, the shoulder. Tissue ochronosis caused by alkaptonuria can cause significant damage to the joint and surrounding soft tissue envelope. In this case, we presented a patient who has end-stage glenohumeral arthritis and rotator cuff arthropathy secondary to ochronosis. Case Presentation: In this case report, we present a 42-year-old male patient who presented to the clinic with severe right shoulder pain and limitations of the range of motion, especially with abduction. The patient underwent radiographic assessment, which showed a rotator cuff arthropathy combined with advanced degenerative changes of the right glenohumeral joint. The patient underwent reverse total shoulder arthroplasty. After the surgery and on follow-up later on for a period of one year and after a period of physiotherapy and rehabilitation, the patient showed remarkable improvement in the pain and range of motion. Conclusion: Alkaptonuria can have a detrimental effect on the articular cartilage and the surrounding soft tissue envelope, which might manifest clinically as early degenerative arthritis changes in a young adult patient. Shoulder involvement is extremely rare and can manifest with substantial injury to the glenohumeral joint; whenever such extensive damage is present, shoulder arthroplasty is the best treatment.

Esmolol Is Not the Solution: Thyroid Storm With Atrial Fibrillation.

Thyroid storm is a challenging medical emergency that requires urgent assessment and management in a timely manner. In this article, we report on a case of a 37-year-old female who presented to the emergency department with a thyroid storm complicated by atrial fibrillation (AF) with a rapid ventricular response with no clinical signs of heart failure. As part of her medical management to rate control her AF, she was started on an infusion of a short-acting beta blocker, esmolol, and shortly after, she developed cardiac arrest. This is the second case report published to highlight the significant response (cardiac arrest) of patients with thyroid storm complicated by AF to a low dose esmolol infusion as part of their medical management.

Neurotrophic keratopathy as a complication of scleral fixated intraocular lens implantation.

PURPOSE: To report a series of patients who developed neurotrophic keratopathy following scleral fixation of intraocular lenses. METHODS: Retrospective case series of patients undergoing implantation of scleral fixated IOLs with various techniques. RESULTS: Three patients developed NK in the immediate post-operative period following scleral fixation of IOLs. Scleral fixation of IOL was performed using three different techniques (4-point fixation, "Yamane" flanged intrascleral and tunneled intrascleral haptic fixation). None of the patient had any prior risk factors for the development of NK. In all patients, intrascleral haptics or scleral sutures were positioned on the horizontal meridian. All patients also underwent light peripheral retinal endolaser. CONCLUSIONS: NK can rarely occur following scleral fixation of IOLs. The combination of suturing or intrascleral fixation of the IOL on the horizontal meridian and peripheral retinal endolaser may synergistically damage to the long ciliary nerves with a "two-hit" mechanism and cause NK.

The Fusiform and Occipital Face Areas Can Process a Nonface Category Equivalently to Faces.

The fusiform and occipital face areas (FFA and OFA) are functionally defined brain regions in human ventral occipitotemporal cortex associated with face perception. There is an ongoing debate, however, whether these regions are face-specific or whether they also facilitate the perception of nonface object categories. Here, we present evidence that, under certain conditions, bilateral FFA and OFA respond to a nonface category equivalently to faces. In two fMRI sessions, participants performed same-different judgments on two object categories (faces and chairs). In one session, participants differentiated between distinct exemplars of each category, and in the other session, participants differentiated between exemplars that differed only in the shape or spatial configuration of their features (featural/configural differences). During the latter session, the within-category similarity was comparable for both object categories. When differentiating between distinct exemplars of each category, bilateral FFA and OFA responded more strongly to faces than to chairs. In contrast, during featural/configural difference judgments, bilateral FFA and OFA responded equivalently to both object categories. Importantly, during featural/configural difference judgments, the magnitude of activity within FFA and OFA evoked by the chair task predicted the participants' behavioral performance. In contrast, when participants differentiated between distinct chair exemplars, activity within these face regions did not predict the behavioral performance of the chair task. We conclude that, when the within-category similarity of a face and a nonface category is comparable and when the same cognitive strategies used to process a face are applied to a nonface category, the FFA and OFA respond equivalently to that nonface category and faces.

Novel intronic RHD variants identified in serologically D-negative blood donors.

BACKGROUND: Blood group genotyping is used to predict RhD phenotype in transfusion and obstetric medicine. Prediction of antigen D is based on molecular techniques which targets most common RHD-specific polymorphism. However, inactive RHD variants can suggest false-positive RhD phenotype. Their types and frequencies vary among ethnicities. Our study aimed to identify RHD variants among Moroccan blood donors who are serologically D negative. STUDY DESIGN AND METHODS: DNA from 53 blood donors who are serologically D negative RhC and/or RhE positive were screened for RHD exon 10 by PCR-SSP. RHD-positive samples were further tested by multiplex PCR covering exons 3, 4, 5, 6, 7 and 9 and then sequenced by targeted next-generation sequencing method. Mutations' impact on mRNA splicing was predicted using alamut software version 2·0. RESULTS: PCR-SSP revealed 9 of 53 (16·9%) RHD-positive samples. Five of nine samples were positive for all tested exons, two of nine were positive for exon 9, and two of nine were undetermined. Sequencing revealed four novel RHD variants based on six mutations in introns 1, 3, 5 and 6. In silico analysis revealed aberrant splicing of three mutations (RHD c.487-1024delG, RHD c.487-256T>G and RHD c.940-187_940-188del), while three other mutations (RHD c.149-682C>A, RHD c.802-37delA and RHD c.939 + 1151dup) had no effect on splicing compared to wild type. CONCLUSIONS: All identified RHD variants contain at least one mutation that probably affects splicing to generate D-negative phenotype. Hence, ethnic RhD antigen background must be considered when developing transfusion and obstetric strategies.

Spatial Mechanisms within the Dorsal Visual Pathway Contribute to the Configural Processing of Faces.

Human face recognition is often attributed to configural processing; namely, processing the spatial relationships among the features of a face. If configural processing depends on fine-grained spatial information, do visuospatial mechanisms within the dorsal visual pathway contribute to this process? We explored this question in human adults using functional magnetic resonance imaging and transcranial magnetic stimulation (TMS) in a same-different face detection task. Within localized, spatial-processing regions of the posterior parietal cortex, configural face differences led to significantly stronger activation compared to featural face differences, and the magnitude of this activation correlated with behavioral performance. In addition, detection of configural relative to featural face differences led to significantly stronger functional connectivity between the right FFA and the spatial processing regions of the dorsal stream, whereas detection of featural relative to configural face differences led to stronger functional connectivity between the right FFA and left FFA. Critically, TMS centered on these parietal regions impaired performance on configural but not featural face difference detections. We conclude that spatial mechanisms within the dorsal visual pathway contribute to the configural processing of facial features and, more broadly, that the dorsal stream may contribute to the veridical perception of faces.

PET-CT for staging and early response: results from the Response-Adapted Therapy in Advanced Hodgkin Lymphoma study.

International guidelines recommend that positron emission tomography-computed tomography (PET-CT) should replace CT in Hodgkin lymphoma (HL). The aims of this study were to compare PET-CT with CT for staging and measure agreement between expert and local readers, using a 5-point scale (Deauville criteria), to adapt treatment in a clinical trial: Response-Adapted Therapy in Advanced Hodgkin Lymphoma (RATHL). Patients were staged using clinical assessment, CT, and bone marrow biopsy (RATHL stage). PET-CT was performed at baseline (PET0) and after 2 chemotherapy cycles (PET2) in a response-adapted design. PET-CT was reported centrally by experts at 5 national core laboratories. Local readers optionally scored PET2 scans. The RATHL and PET-CT stages were compared. Agreement among experts and between expert and local readers was measured. RATHL and PET0 stage were concordant in 938 (80%) patients. PET-CT upstaged 159 (14%) and downstaged 74 (6%) patients. Upstaging by extranodal disease in bone marrow (92), lung (11), or multiple sites (12) on PET-CT accounted for most discrepancies. Follow-up of discrepant findings confirmed the PET characterization of lesions in the vast majority. Five patients were upstaged by marrow biopsy and 7 by contrast-enhanced CT in the bowel and/or liver or spleen. PET2 agreement among experts (140 scans) with a κ (95% confidence interval) of 0.84 (0.76-0.91) was very good and between experts and local readers (300 scans) at 0.77 (0.68-0.86) was good. These results confirm PET-CT as the modern standard for staging HL and that response assessment using Deauville criteria is robust, enabling translation of RATHL results into clinical practice.

Common Dorsal Stream Substrates for the Mapping of Surface Texture to Object Parts and Visual Spatial Processing.

Everyday objects are often composed of multiple parts, each with a unique surface texture. The neural substrates mediating the integration of surface features on different object parts are not fully understood, and potential contributions by both the ventral and dorsal visual pathways are possible. To explore these substrates, we collected fMRI data while human participants performed a difference detection task on two objects with textured parts. The objects could either differ in the assignment of the same texture to different object parts ("texture-location") or the types of texture ("texture-type"). In the ventral stream, comparable BOLD activation levels were observed in response to texture-location and texture-type differences. In contrast, in a priori localized spatial processing regions of the dorsal stream, activation was greater for texture-location than texture-type differences, and the magnitude of the activation correlated with behavioral performance. We confirmed the reliance of surface texture to object part mapping on spatial processing mechanisms in subsequent psychophysical experiments, in which participants detected a difference in the spatial distance of an object relative to a reference line. In this task, distracter objects occasionally appeared, which differed in either texture-location or texture-type. Distracter texture-location differences slowed detection of spatial distance differences, but texture-type differences did not. More importantly, the distracter effects were only observed when texture-location differences were presented within whole shapes and not between separated shape parts at distinct spatial locations. We conclude that both the mapping of texture features to object parts and the representation of object spatial position are mediated by common neural substrates within the dorsal visual pathway.

Clinical presentation, severity and progression of primary angle closure in malays.

INTRODUCTION: There is limited knowledge on primary angle closure (PAC) in Malays. Understanding the clinical presentation and progression of PAC in Malays is important for prevention of blindness in Southeast Asia. MATERIAL AND METHODS: A retrospective record review study was conducted on Malay patients seen in the eye clinic of two tertiary hospitals in Kelantan, Malaysia. Based on the available data, Malay patients re-diagnosed as primary angle closure suspect (PACS), primary angle closure (PAC), and primary angle closure glaucoma (PACG) based on the International Society Geographical Epidemiological classification. Clinical data was collected from initial presentation including the presence of acute primary angle closure until at least 5 years follow up. Progression was defined based on gonioscopic changes, vertical cup to disc ratio (VCDR), intraocular pressure (IOP) and Humphrey visual field (HVF) analysis. Progression and severity of PACG was defined based Hodapp-Parrish-Anderson classification on reliable HVF central 24-2 or 30-2 analysis. RESULTS: A total of 100 patients (200 eyes) with at least 5 years follow up were included. 94 eyes (47%) presented with APAC. During initial presentation, 135 eyes (67.5%) were diagnosed with glaucomatous changes with 91 eyes already blind. After 5 years of follow up, 155 eyes (77.5%) progressed. There was 4 times risk of progression in eyes with PAC (p=0.071) and 16 times risk of progression in PACG (p=0.001). Absence of laser peripheral iridotomy was associated with 10 times the risk of progression. CONCLUSION: Angle closure is common in Malays. Majority presented with optic neuropathy at the initial presentation and progressed further. Preventive measures including promoting public awareness among Malay population is important to prevent blindness.

Novel presenilin mutations within Moroccan patients with Early-Onset Alzheimer's Disease.

Alzheimer's disease (AD) is a progressive brain disorder that causes gradual and irreversible loss of higher brain functions and is the most common cause of dementia in the elderly, as assessed by autopsy and clinical series. Furthermore, it has an annual incidence of approximately 3% in the 65-74-year-old age group. This incidence rate doubles with every increment of 5 years above the age of 65. In Morocco, AD affects almost 30,000 individuals and this number will possibly increase to 75,000 by 2020 (projections of the World Health Organization (WHO)). Genetically, AD is caused by a mutation in one of at least 3 genes: presenilin 1 (PS1), presenilin 2 (PS2) and the amyloid precursor protein (APP). Most cases are late onset and apparently sporadic, most likely as a result of a combination of environmental and non-dominant genetic factors. In Morocco, the genes predisposing individuals to AD and predicting disease incidence remain elusive. The purpose of the present study was to evaluate the genetic contribution of mutations in PS1 and PS2 genes to familial early-onset AD cases and sporadic late-onset AD cases. Seventeen sporadic late-onset AD cases and eight familial early-onset AD cases were seen at the memory clinic of the University of Casablanca Neurology Department. These patients underwent standard somatic neurological examination, cognitive function assessment, brain imaging and laboratory tests. Direct sequencing of each exon in PS1 and PS2 genes was performed on genomic DNA of AD patients. Further, we identified 1 novel frameshift mutation in the PS1 gene and 2 novel frameshift mutations in the PS2 gene. Our mutational analysis reports a correlation between clinical symptoms and genetic factors in our cases of Early-Onset Alzheimer's Disease (EOAD). These putative mutations cosegregate with affected family members suggesting a direct mutagenic effect.

Educational outcomes of The University of Toronto Visiting Professor Rounds Series.

OBJECTIVE: To assess how the University of Toronto Visiting Professors Rounds Series (UTVPRS) influenced the knowledge, perceptions, and clinical decision making of Canadian ophthalmologists. DESIGN: Longitudinal cross-sectional. PARTICIPANTS: Eight hundred and fifty ophthalmologists registered with the Canadian Ophthalmological Society. METHODS: Online surveys, using multiple-choice and reflection questions, were administered before and after online viewing of the University of Toronto Ophthalmology grand rounds as screencasts. RESULTS: At 18 months, 124 users registered and watched 429 screencasts. Most participants found UTVPRS to be organized and user friendly. Mean prescreencast correct scores were 1008 versus 1288 postscreencast (p = 0.002). Postscreencast, 73% of participants replied in favour of changing future practice. CONCLUSIONS: UTVPRS was well received with demonstrated knowledge gain and potential practice change. The long-term and patient-related outcomes of the results require further research.

Induction of complete and mosaic sex-linked recessive lethal mutations by cigarette smoke filtrate in Drosophila melanogaster.

The genotoxic effects of cigarette smoke filtrate (SF) on the germ-line stages were examined in Drosophila melanogaster using the sex-linked recessive lethal test, which detects a broad spectrum of genetic alterations and proved to show correlations between mutagenicity and carcinogenicity of the tested chemicals. SF was extracted from fiberglass filter cartridges; each used in smoking 15 cigarettes. The proper SF concentrations (0.2 µL) in 0.45% NaCl saline were injected intraperitoneally in 2- to 3-day-old wild-type males, alongside with controls injected with 0.2 µL of saline. The genotoxicity effects of SF were examined in all spermatogenesis stages of treated males. Results showed that SF was toxic with an median lethal dose value of approximately 0.2% and induced significant sterility effects. The mutagenicity of SF (0.2%) was significantly stage specific and induced complete sex-linked recessive lethal mutations in the broods representing the spermatocytes and late and early spermatogonia, and induced mosaic mutations in the untreated progeny in the brood representing late spermatogonia. These results indicated, for the first time, that SF induces mosaic mutations, which could result from DNA instabilities and labile permutations that can be replicated and passed to future generations before being fixed into mutations in the untreated progeny of treated males, or originating from mutations that result in increasing hyperplasia of the gonad that subsequently produce the actual mutations in later cell cycles. Such delayed mutagenic effects of SF indicated that SF and, consequently, cigarette smoking have much greater genotoxicity than what was previously predicted.

Generic versus brand-name North American topical glaucoma drops.

OBJECTIVE: To determine whether brand-name glaucoma drops differ from generic equivalents in bottle design, viscosity, surface tension, and volume in North America. DESIGN: Experimental study. PARTICIPANTS: We studied 5 bottles each of 11 kinds of glaucoma drops. METHODS: Density-based calculations of drop volume were assessed using 0.1 mg analytic balance. Viscosity was measured using rotational rheometery. Bottle tip diameter was measured using 0.05 mm Vernier calipers. Surface tension was measured using a Fisher Scientific (Ottawa, ON) tensiometer. RESULTS: For the American brand-name Timoptic XE, the average drop volume was 38 ± 3.1 µL versus 24 ± 1.5 µL of Timolol GFS (p < 0.0001). For the Canadian brand-name Timoptic XE, the average drop volume was 42 ± 4.0 µL versus 25 ± 2 µL of timolol maleate EX (p < 0.0001). The Canadian brand-name Timoptic drop volume was 28 ± 1.4 µL versus 35 ± 1.9 µL Apo-Timop (p < 0.01). At a 0.1 per second shear rate, the viscosity of Canadian Timoptic XE was 20 times higher than that of its generic equivalent, whereas the viscosity of American Timoptic XE differed from the generic by a factor of 100. The surface tension of Canadian Timoptic XE was 31% higher than that of the generic (p < 0.001), whereas the surface tension of American Timoptic XE was 21% higher than that of the generic (p < 0.001). The bottle tips of the Canadian and American Timoptic XE measured about 3.5 times larger than those of their generics. CONCLUSION: American and Canadian Timoptic XE eye drops vary significantly from the generics in drop volume, viscosity, surface tension, and bottle tip. Canadian brand-name Timoptic delivered significantly smaller drop volumes than generic Apo-Timop. Careful consideration should be given to drop viscosity and bottle design when generic ophthalmic products are evaluated for interchangeability and market entry.

Low carbohydrate ketogenic diet prevents the induction of diabetes using streptozotocin in rats.

Diabetes continues to be an overwhelmingly prevalent endocrine disorder that leads to several micro- and macrocomplications. It has been widely accepted that changes in dietary habits could induce or prevent the onset of diabetes. It is shown that low carbohydrate ketogenic diet (LCKD) is effective in the amelioration of many of the deleterious consequences of diabetes. However, its role in preventing the onset of diabetes is not understood. Therefore, this study is focused on the effect of LCKD in preventing the induction of diabetes using streptozotocin (STZ) in rats by biochemical and histological methods. Forty-two Wistar rats weighing 150-250 g were used in this study. The animals were divided into three groups: normal diet (ND), low carbohydrate ketogenic diet (LCKD), and high carbohydrate diet (HCD). Specific diets ad libitum were given to each group of animals for a period of 8 weeks. Each group was further subdivided into normal control, sham control and diabetic groups. Animals in the diabetic group were given a single intraperitoneal injection of STZ (55 mg/kg). All the animals were sacrificed 4 weeks after the injection of STZ. Daily measurements of food and water intake as well as weekly measurement of body weight were taken during the whole 12 weeks of the experiment. After injecting with STZ, the blood glucose level of all the groups increased significantly except for the group fed on LCKD (p value<0.01). Also, food intake, water intake and urine output were significantly increased in all groups except for the LCKD group (p value<0.01). There was also a significant decrease in the weight gain of the animals that were fed on a LCKD as compared to other groups (p value<0.05). Although, substantial decrease in the number of ß cells was noticed in diabetic rats, there were no change in the number of ß cells in the LCKD treated diabetic animals as compared to LCKD control group. The results presented in this study, therefore, suggests that LCKD prevents the development of diabetes using streptozotocin in rats.

The potential therapeutic effect of nitric oxide modulators in experimentally-induced gastric ulcers.

Nitric oxide (NO) appears to play a critical role in modulating gastric mucosal defense. Administration of NO donors has been reported to protect the gastrointestinal mucosa against damage induced by several irritants. However, the possible role of NO in healing existing ulcers must be clarified further. Therefore, the present study was designed to assess the effect of modulation of NO on the healing of an indomethacin-induced peptic ulcer using a NO precursor, L-arginine, and a competitive inhibitor of NO synthase, L-NAME. Results of administering L-arginine were compared to those using nitroglycerin (NTG), an NO donor. Rats were injected with a single oral dose of indomethacin (30 mg/kg) and then treated with L-arginine (200 mg/kg, i.p.), NTG (1 mg/kg, i.p.) or L-NAME (15 mg/kg, i.p.) once daily for 7 d starting 4 h after the indomethacin injection. Gross lesion examination and histological assessment were done. NO, prostaglandin (PGE2), and mucin content in gastric tissue were detected. In addition, oxidative stress markers including glutathione (GSH) and lipid peroxides were measured. L-arginine and NTG almost completely healed indomethacin-induced ulceration as indicated by macroscopic and histological examination, restoration of normal levels of NO and GSH, and a significant attenuation of the increase in PGE2 and lipid peroxides induced by indomethacin. In contrast, L-NAME was found to exacerbate mucosal damage. In conclusion, the present study provides further evidence for the role of NO in gastric ulcer healing and it suggests an alternative path to treating the universal problem of non-steroidal anti-inflammatory-drug-induced gastropathy.