Combinatorial Hypofractionated Radiotherapy and Pembrolizumab in Anaplastic Thyroid Cancer.

Objectives Anaplastic thyroid cancer (ATC) is an aggressive disease associated with poor outcomes and resistance to therapies. Our study aim was to evaluate the activity of a combinatorial regimen of sandwich sequencing of pembrolizumab immunotherapy and hypofractionated radiotherapy (RT). Methods In this case series, patients with ATC received hypofractionated RT (QUAD-shot) and intravenous pembrolizumab 200mg every 3-4 weeks. Pembrolizumab was continued until disease progression or up till 24 months. Concurrent Lenvatinib treatment was allowed. Primary endpoint was best overall response (BOR) and progression-free survival (PFS). Additionally, we performed immune profiling of circulating T cells in a responder to investigate the immune response to our combinatorial treatment. Results At median follow-up of 32.6 months (IQR: 26.4-38.8), of a cohort of 5 patients, BOR was 80%; with 2 complete responses (CR) and 2 partial responses (PR). Patients who achieved CR remained disease-free at last follow-up. Median PFS was 7.6 months (IQR: 6.2-NR), and 1-year PFS and overall survival rate was 40% (95% CI: 13.7-100) for both. Treatment was well-tolerated, with mostly grade 1-2 adverse events. Immune profiling of one partial responder revealed an increase in activated CD4 and CD8 T cells post-QUAD-shot RT, which was further enhanced during the maintenance phase of pembrolizumab. Conclusions Herein, we reported a case series of 5 patients with ATC, with 2 long-term survivors who were treated with surgical debulking followed by QUAD-shot RT and pembrolizumab, possibly due to synergy of local and systemic treatments in activating anti-tumour immunogenic cytotoxicity. This regimen warrants further investigation in a larger cohort of patients.

Automated indexing using NLM's Medical Text Indexer (MTI) compared to human indexing in Medline: a pilot study.

Objective: In 2002, the National Library of Medicine (NLM) introduced semi-automated indexing of Medline using the Medical Text Indexer (MTI). In 2021, NLM announced that it would fully automate its indexing in Medline with an improved MTI by mid-2022. This pilot study examines indexing using a sample of records in Medline from 2000, and how an early, public version of MTI's outputs compares to records created by human indexers. Methods: This pilot study examines twenty Medline records from 2000, a year before the MTI was introduced as a MeSH term recommender. We identified twenty higher- and lower-impact biomedical journals based on Journal Impact Factor (JIF) and examined the indexing of papers by feeding their PubMed records into the Interactive MTI tool. Results: In the sample, we found key differences between automated and human-indexed Medline records: MTI assigned more terms and used them more accurately for citations in the higher JIF group, and MTI tended to rank the Male check tag more highly than the Female check tag and to omit Aged check tags. Sometimes MTI chose more specific terms than human indexers but was inconsistent in applying specificity principles. Conclusion: NLM's transition to fully automated indexing of the biomedical literature could introduce or perpetuate inconsistencies and biases in Medline. Librarians and searchers should assess changes to index terms, and their impact on PubMed's mapping features for a range of topics. Future research should evaluate automated indexing as it pertains to finding clinical information effectively, and in performing systematic searches.

Synthesis of Chiral Hypervalent Trifluoromethyl Organobismuth Complexes and Enantioselective Olefin Difluorocarbenation Screenings.

Two hypervalent trifluoromethyl organobismuth complexes were prepared from commercially available chiral amines, (R)-1-cyclohexylethylamine and (1R, 2R, 3R, 5S)-(-)-isopinocampheylamine; however, only the complex from the latter amine was prepared as a single stereoisomer. Both organobismuth complexes were fully characterized by NMR spectroscopy and single-crystal X-ray crystallography, revealing that the structures were similar to previously reported complexes with a hypervalent Bi-N bond. The complexes were catalytically active in olefin difluorocarbenation with Ruppert-Prakash reagent (TMS-CF3 ) used as a terminal source of CF2 . The catalyst derived from isopinocampheylamine was screened with three prochiral olefins of various reactivity in DCM and toluene. All reactions afforded the 1,1-difluorocyclopropanes in good yields, but no enantiomeric excess was observed.

An emerging master inducer and regulator for epithelial-mesenchymal transition and tumor metastasis: extracellular and intracellular ATP and its molecular functions and therapeutic potential.

Despite the rapid development of therapeutic strategies in cancer treatment, metastasis remains the major cause of cancer-related death and scientific challenge. Epithelial-Mesenchymal Transition (EMT) plays a crucial role in cancer invasion and progression, a process by which tumor cells lose cell-cell adhesion and acquire increased invasiveness and metastatic activity. Recent work has uncovered some crucial roles of extracellular adenosine 5'- triphosphate (eATP), a major component of the tumor microenvironment (TME), in promoting tumor growth and metastasis. Intratumoral extracellular ATP (eATP), at levels of 100-700 µM, is 103-104 times higher than in normal tissues. In the current literature, eATP's function in promoting metastasis has been relatively poorly understood as compared with intracellular ATP (iATP). Recent evidence has shown that cancer cells internalize eATP via macropinocytosis in vitro and in vivo, promoting cell growth and survival, drug resistance, and metastasis. Furthermore, ATP acts as a messenger molecule that activates P2 purinergic receptors expressed on both tumor and host cells, stimulating downstream signaling pathways to enhance the invasive and metastatic properties of tumor cells. Here, we review recent progress in understanding eATP's role in each step of the metastatic cascade, including initiating invasion, inducing EMT, overcoming anoikis, facilitating intravasation, circulation, and extravasation, and eventually establishing metastatic colonization. Collectively, these studies reveal eATP's important functions in many steps of metastasis and identify new opportunities for developing more effective therapeutic strategies to target ATP-associated processes in cancer.

Urine drug screening on labor and delivery.

BACKGROUND: Substance use including opioids, methamphetamines, benzodiazepines, and barbiturates during pregnancy is harmful for the pregnant person and the fetus. Routine screening using validated questionnaires is recommended, but often biologic sampling is done instead. There is often bias in urine drug screening on labor and delivery units. OBJECTIVE: This study aimed to compare characteristics of people who did and did not receive urine drug screening during labor and delivery and to examine the relationship of maternal results to neonatal results. STUDY DESIGN: This was a retrospective chart review examining all people in 2017 who delivered in the labor and delivery unit at our institution. We collected urine drug screening result information, maternal demographic data, follow-up after positive maternal tests, and neonatal test results. Individual characteristics and obstetrical outcomes were analyzed. RESULTS: Of 6265 deliveries, 297 urine drug screening tests were ordered. People who were tested identified most commonly as Native Hawaiian or Pacific Islander (P<.0001). The most common indications for ordering tests were a history of substance use and insufficient prenatal care (P<.0001). People who tested positive were more likely to self-identify as White (P=.03) and have history of substance use (P<.0001). Among the positive test results, 24 (24%) were caused by a provider-ordered medication. Self-identification as Native Hawaiian or Pacific Islander was not predictive of a positive result. Of the tested people, 36% (108/297) had a positive result on preliminary testing, and 33% (98/295) on confirmatory testing. CONCLUSION: Native Hawaiians and Pacific Islanders were more likely to undergo testing, whereas White people were more likely to have a positive result. Maternal results were not reliable for predicting neonatal drug test results and vice versa. With rising rates of substance use disorders in the pregnant and reproductive-age population, standardized unbiased race-neutral guidelines for urine drug screening should be implemented using laboratory test results that include preliminary and reflex confirmatory results.

Patients Perceptions of Artificial Intelligence in Diabetic Eye Screening.

PURPOSE: Artificial intelligence (AI) technology is poised to revolutionize modern delivery of health care services. We set to evaluate the patient perspective of AI use in diabetic retinal screening. DESIGN: Survey. METHODS: Four hundred thirty-eight patients undergoing diabetic retinal screening across New Zealand participated in a survey about their opinion of AI technology in retinal screening. The survey consisted of 13 questions covering topics of awareness, trust, and receptivity toward AI systems. RESULTS: The mean age was 59 years. The majority of participants identified as New Zealand European (50%), followed by Asian (31%), Pacific Islander (10%), and Maori (5%). Whilst 73% of participants were aware of AI, only 58% have heard of it being implemented in health care. Overall, 78% of respondents were comfortable with AI use in their care, with 53% saying they would trust an AI-assisted screening program as much as a health professional. Despite having a higher awareness of AI, younger participants had lower trust in AI systems. A higher proportion of Maori and Pacific participants indicated a preference toward human-led screening. The main perceived benefits of AI included faster diagnostic speeds and greater accuracy. CONCLUSIONS: There is low awareness of clinical AI applications among our participants. Despite this, most are receptive toward the implementation of AI in diabetic eye screening. Overall, there was a strong preference toward continual involvement of clinicians in the screening process. There are key recommendations to enhance the receptivity of the public toward incorporation of AI into retinal screening programs.

The effect of perioperative sustained-release opioid use on long-term opioid dispensing following total knee arthroplasty: a retrospective cohort study.

AIMS: To determine the impact of perioperative sustained-release (SR) opioid use on total inpatient opioid consumption and longer-term outpatient dispensing for three months following elective total knee arthroplasty (TKA). METHODS: Patients who underwent primary unilateral TKA between 1 January and 31 December 2018 at Counties Manukau Health were retrospectively identified. Participants were stratified into two groups by inpatient use or avoidance of strong SR opioids (OxyContin or M-Eslon). The primary outcome was the percentage of patients receiving prescriptions for opioid medications at thirty-day intervals for three months after discharge. RESULTS: Two hundred and thirty-two patients were eligible for inclusion. The baseline demographics of both groups were similar. In the SR opioid use group, the majority (79%) received OxyContin. Overall, inpatient opioid use between postoperative days (POD) zero and three was lower in the SR opioid avoidance group, although this was not statistically significant (157.5 [IQR 110.0-220.0] vs 167.5mg OME [110.0-290.0], p=0.14). Outpatient postoperative opioid dispensing between 0-30 days was significantly greater in patients who received inpatient SR opioids (p=0.01). Dispensing of oxycodone was significantly higher in the SR opioid use group at one- and two- months (p=0.01 and 0.03 respectively). CONCLUSION: The postoperative use of SR opioids is not routinely recommended following TKA. Their use is associated with greater overall inpatient opioid use, sustained opioid dispensing during and after the expected recovery period, and the potential for significant harm.

The absolute and relative risk of type 2 diabetes after gestational diabetes: A systematic review and meta-analysis of 129 studies.

AIMS: To estimate development of type 2 diabetes (T2DM) in women with previous gestational diabetes (GDM) and investigate characteristics associated with higher diagnoses, building on previous meta-analyses and exploring heterogeneity. METHODS: Systematic literature review of studies published up to October 2019. We included studies reporting progression to T2DM ≥6 months after pregnancy, if diagnostic methods were reported and ≥50 women with GDM participated. We conducted random-effects meta-analyses and meta-regression of absolute and relative T2DM risk. PROSPERO ID: CRD42017080299. RESULTS: In 129 included studies, the percentage diagnosed with T2DM was 12% (95% confidence interval 8-16%) higher for each additional year after pregnancy, with a third developing diabetes within 15 years. Development was 18% (5-34%) higher per unit BMI at follow-up, and 57% (39-70%) lower in White European populations compared to others (adjusted for ethnicity and follow-up). Women with GDM had a relative risk of T2DM of 8.3 (6.5-10.6). 17.0% (15.1-19.0%) developed T2DM overall, although heterogeneity between studies was substantial (I2 99.3%), and remained high after accounting for various study-level characteristics. CONCLUSIONS: Percentage developing T2DM after GDM is highly variable. These findings highlight the need for sustained follow-up after GDM through screening, and interventions to reduce modifiable risk factors.

The Effect of Positive and Negative Poster Messages on Organ Donor Registration.

BACKGROUND: There is a mismatch between the number of people who require transplants and the number of organ donors. Promotional materials have been shown to increase rates of organ donor registration. This study assessed the impact on the intention to join the organ donor registry of a gain-framed message about lives saved through organ donation compared to a loss-framed message about lives lost waiting for a transplant. METHODS: Two posters were designed that were identical other than the slogan. One slogan was gain-framed: "One organ donor can save 9 lives!" and the other loss-framed: "3 people die every day in the UK waiting for an organ transplant." Twenty copies of each were distributed between hospitals in Cambridge and Newcastle, UK, for 20 weeks. After 10 weeks, the gain-framed and loss-framed posters swapped locations. Each poster had a QR code that linked to the online organ donor register sign-up form, and the click-through rate was used to determine registration. Analysis was performed using a 2-tailed sign binomial test. RESULTS: Sixty-eight registrations occurred over a 20-week period. Overall, there was no significant difference in registrations between gain- and loss-framed posters (37 vs 31, P = .54). However, poster location influenced registration, as prior to the location swap there was a significant difference in gain-framed vs loss-framed posters (28 vs 10, P = .005). Additionally, registration was significantly higher in Cambridge vs Newcastle (47 vs 21, P = .01). CONCLUSIONS: Posters can increase organ donor register (ODR) registration independent of gain- or loss-framing. However, poster location, both intra- and inter-hospital, significantly influences effectiveness.

Central Airway Toxicity After High Dose Radiation: A Combined Analysis of Prospective Clinical Trials for Non-Small Cell Lung Cancer.

PURPOSE: To study the dosimetric risk factors for radiation-induced proximal bronchial tree (PBT) toxicity in patients treated with radiation therapy for non-small cell lung cancer (NSCLC). METHODS AND MATERIALS: Patients with medically inoperable or unresectable NSCLC treated with conventionally fractionated 3-dimensional conformal radiation therapy (3DCRT) in prospective clinical trials were eligible for this study. Proximal bronchial tree (PBT) and PBT wall were contoured consistently per RTOG 1106 OAR-Atlas. The dose-volume histograms (DVHs) of physical prescription dose (DVHp) and biological effective dose (α/ß = 2.5; DVH2.5) were generated, respectively. The primary endpoint was PBT toxicities, defined by CTCAE 4.0 under the terminology of bronchial stricture/atelectasis. RESULTS: Of 100 patients enrolled, with a median follow-up of 64 months (95% confidence interval [CI], 50-78), 73% received 70 Gy or greater and 17% developed PBT toxicity (grade 1, 8%; grade 2, 6%; grade 3, 0%; and grade 4, 3%). The median time interval between RT initiation and onset of PBT toxicity was 8.4 months (95% CI, 4.7-44.1). The combined DVHs showed that no patient with a PBT maximum physical dose <65 Gy developed any PBT toxicity. Cox proportional hazards analysis and receiver operating characteristic analysis demonstrated that V75 of PBT was the most significant dosimetric parameter for both grade 1+ (P = .035) and grade 2+ (P = .037) PBT toxicities. The dosimetric thresholds for V75 of PBT were 6.8% and 11.9% for grade 1+ and grade 2+ PBT toxicity, respectively. CONCLUSIONS: V75 of PBT appeared be the most significant dosimetric parameter for PBT toxicity after conventionally fractionated thoracic 3DCRT. Constraining V75 of PBT can limit clinically significant PBT toxicity.

Current Understanding of Host Genetics of Otitis Media.

The pathogenesis of otitis media (OM), an inflammatory disease of the middle ear (ME), involves interplay between many different factors, including the pathogenicity of infectious pathogens, host immunological status, environmental factors, and genetic predisposition, which is known to be a key determinant of OM susceptibility. Animal models and human genetics studies have identified many genes and gene variants associated with OM susceptibility: genes that encode components of multiple signaling pathways involved in host immunity and inflammatory responses of the ME mucosa; genes involved in cellular function, such as mucociliary transport, mucin production, and mucous cell metaplasia; and genes that are essential for Eustachian tube (ET) development, ME cavitation, and homeostasis. Since our last review, several new mouse models with mutations in genes such as CCL3, IL-17A, and Nisch have been reported. Moreover, genetic variants and polymorphisms in several genes, including FNDC1, FUT2, A2ML1, TGIF1, CD44, and IL1-RA variable number tandem repeat (VNTR) allele 2, have been identified as being significantly associated with OM. In this review, we focus on the current understanding of the role of host genetics in OM, including recent discoveries and future research prospects. Further studies on the genes identified thus far and the discovery of new genes using advanced technologies such as gene editing, next generation sequencing, and genome-wide association studies, will advance our understanding of the molecular mechanism underlying the pathogenesis of OM and provide new avenues for early screening and developing effective preventative and therapeutic strategies to treat OM.

Fragile X mental retardation protein: A paradigm for translational control by RNA-binding proteins.

Translational control is a common mechanism used to regulate gene expression and occur in bacteria to mammals. Typically in translational control, an RNA-binding protein binds to a unique sequence in the mRNA to regulate protein synthesis by the ribosomes. Alternatively, a protein may bind to or modify a translation factor to globally regulate protein synthesis by the cell. Here, we review translational control by the fragile X mental retardation protein (FMRP), the absence of which causes the neurological disease, fragile X syndrome (FXS).

Fragile X mental retardation protein regulates translation by binding directly to the ribosome.

Fragile X syndrome (FXS) is the most common form of inherited mental retardation, and it is caused by loss of function of the fragile X mental retardation protein (FMRP). FMRP is an RNA-binding protein that is involved in the translational regulation of several neuronal mRNAs. However, the precise mechanism of translational inhibition by FMRP is unknown. Here, we show that FMRP inhibits translation by binding directly to the L5 protein on the 80S ribosome. Furthermore, cryoelectron microscopic reconstruction of the 80S ribosome⋅FMRP complex shows that FMRP binds within the intersubunit space of the ribosome such that it would preclude the binding of tRNA and translation elongation factors on the ribosome. These findings suggest that FMRP inhibits translation by blocking the essential components of the translational machinery from binding to the ribosome.

Knee pain in patients with cancer after chemotherapy, radiotherapy, and bone marrow transplantation.

The causes of knee pain in patients with cancer with are different from those without cancer, and the purpose of this study was to evaluate these differences. Thirty-six patients with cancer who had knee pain who had undergone 1 or more modalities of treatment, including chemotherapy, radiotherapy, and bone marrow transplant, for a primary diagnosis of cancer were compared with a cohort of 40 patients without cancer who had knee pain. All patients were evaluated clinically and underwent radiographic examination, and some underwent computed tomography or magnetic resonance imaging examination. Among patients with a primary diagnosis of cancer, the most common diagnosis was lymphoma (n=10), and the most common causes of knee pain were avascular necrosis of bone, osteoarthritis, insufficiency fractures, and septic arthritis. In 5 patients, the classical signs of a septic knee were not present. Other causes of knee pain included meniscus tear and anterior cruciate ligament rupture with instability. The most common diagnosis in patients without cancer was osteoarthritis of the knee. No patient without cancer was diagnosed with avascular necrosis, metastatic lesion, or insufficiency fracture. Two patients without cancer were diagnosed with septic arthritis of the knee. This study showed that the causes of knee pain in patients with cancer are different from those without cancer. Septic arthritis may present without the classical clinical signs in patients with cancer, and a high index of suspicion should be maintained for it.

Active surveillance testing and decontamination strategies in intensive care units to reduce methicillin-resistant Staphylococcus aureus infections.

BACKGROUND: Active surveillance testing (AST) and decontamination strategies (DS) using a topical methicillin-resistant Staphylococcus aureus (MRSA) cleansing agent was introduced in July 2007 in a medical intensive care unit (MICU) and a surgical ICU (SICU) of a tertiary care hospital to reduce the incidence of MRSA infection. METHODS: Data on ICU admissions between July 1, 2007, and June 30, 2008, was analyzed. All subjects, excluding known MRSA status, had an ICU length of stay (LOS) of more than 24 hours and nasal swabs performed on ICU admission, every 7 days during the ICU stay, and on discharge. MICU and SICU specimens were sent for culture and in-house real-time polymerase chain reaction, respectively. MRSA-colonized (MRSAc) patients were subjected to contact isolation precautions and DS for 5 days or until ICU discharge. Data recorded included demographics, LOS, and antibiotic use. Results were analyzed using SPSS. Control charts were used to determine special cause variation. RESULTS: Of 653 eligible patients admitted to the ICU, 85 (13%) were determined to be MRSAc on ICU admission. A further 15% (52 of 351) were determined to be MRSAc during the ICU stay or at discharge. Thus, AST detected MRSA in at least 137 of the 653 patients (21.0%). In contrast, clinical cultures for MRSA were positive in only 12 patients (1.8%). Compared with noncolonized patients, MRSAc patients at any screening point had a longer pre-ICU LOS (P =.001), received more antibiotics (P = .004), and had a longer ICU LOS (P = .003). Compared with the preintervention period of July 2006 to June 2007, there was no significant reduction in mean MRSA infection incidence rate in both ICUs (3.8 to 3.0 per 1000 patient-days [P = .057] in the SICU and 1.4 to 1.7 per 1000 patient-days in the MICU) following intervention. CONCLUSIONS: In ICUs, AST detected 11 times more MRSA than clinical cultures. The lack of reduction in MRSA infection rates in the ICUs does not negate the roles of AST and DS, but does argue for better study design and outcome measures like MRSA transmission incidence, which perhaps would have demonstrated a true benefit of AST and DS.

Prevalence and genotypes of human noroviruses in tropical urban surface waters and clinical samples in Singapore.

The prevalence and genotypes of norovirus genogroup I (GI) and GII in tropical urban catchment waters and an estuarine bay were studied. A comparative analysis was performed with environmental isolates of noroviruses and concurrently identified clinical isolates in Singapore during gastroenteritis outbreaks between August 2006 to January 2007. Noroviruses in environmental water samples were concentrated by using ultrafiltration techniques and then analyzed by reverse transcription-seminested PCR assay targeting the partial capsid region of noroviruses and DNA sequencing. Among the 60 water samples collected, noroviruses were detected in 43 (71.7%) of these samples. Of these 43 norovirus-positive samples, the coexistence of both GI and GII strains was identified in 23 (53.5%) water samples. The phylogenetic analysis revealed multiple genotypes of noroviruses GI and GII in environmental water samples. GI and GII strains were clustered into seven and nine (including two unclassified) genotypes, respectively. The major norovirus genotypes in environmental water samples were GI/2 and GI/4 and GII/4. Genotyping of the 21 norovirus-positive clinical samples showed that all of the strains belonged to the GII/4 cluster. The environmental and clinical norovirus GII/4 isolates showed high levels of nucleotide sequence identity to each other and to the novel GII/4 variant associated with global epidemics of gastroenteritis during 2006. This study suggests the emergence and circulation of multiple novel norovirus GI and GII genotypes in water environments. Further comprehensive surveillance of water environments for noroviruses and routine clinical reporting is warranted.

Expression analysis of fibroblast growth factor-23, matrix extracellular phosphoglycoprotein, secreted frizzled-related protein-4, and fibroblast growth factor-7: identification of fibroblast growth factor-23 and matrix extracellular phosphoglycoprotein as major factors involved in tumor-induced osteomalacia.

OBJECTIVE: To evaluate the expression of various phosphaturic factors in the tumor of a patient with tumor-induced osteomalacia (TIO) and to analyze serum levels of fibroblast growth factor (FGF)-23 in TIO and healthy subjects. METHODS: We measured serum FGF-23 levels in 2 patients with TIO and 6 healthy volunteers. Expression of FGF-23, matrix extracellular phosphoglycoprotein (MEPE), FGF-7, and secreted frizzled-related protein-4 (sFRP-4) was analyzed in a hemangiopericytoma from a patient with TIO, in a hemangiopericytoma from a patient without TIO, and in various control cell lines. RESULTS: Serum FGF-23 levels were substantially higher in patients with TIO in comparison with those in healthy control subjects and normalized with successful resection of the tumor. Tissue expression analysis showed preferential expression of FGF-23 and MEPE in TIO-related hemangiopericytoma, whereas FGF-7 and sFRP-4 were widely expressed in all studied cell lines and tissues. CONCLUSION: These results support the use of FGF-23 measurements for the diagnosis and follow-up of patients with TIO. In addition, the specific expression of FGF-23 and MEPE in the TIO-associated tumor suggests an important role of these two phosphatonins in the pathogenesis of TIO. Because of the limited number of patients in our report, further studies are needed to clarify the role of different phosphatonins in the development of the clinical features of TIO.