Application of a Low-cost, High-fidelity Proximal Phalangeal Dislocation Reduction Model for Clinician Training.

Introduction: Patients present to the emergency department (ED) relatively commonly with traumatic closed proximal interphalangeal joint (PIPJ) dislocations, an orthopedic emergency. There is a paucity of teaching models and training simulations for clinicians to learn either the closed dislocated dorsal or volar interphalangeal joint reduction technique. We implemented a teaching model to demonstrate the utility of a novel reduction model designed from three-dimensional (3D) printable components that are easy to connect and do not require further machining or resin models to complete. Methods: Students watched a two-minute video and a model demonstration by the authors. Learners including emergency medicine (EM) residents and physician assistant fellows assessed model fidelity, convenience, perceived competency, and observed competency. Results: Seventeen of 21 (81%) participants agreed the model mimicked dorsal and volar PIPJ dislocations. Nineteen of 21 (90%) agreed the model was easy to use, 21/21 (100%) agreed the dorsal PIPJ model and 20/21 (95%) agreed the volar PIPJ model improved their competency. Conclusion: Our 3D-printed, dorsal and volar dislocation reduction model is easy to use and affordable, and it improved perceived competency among EM learners at an academic ED.

Ciprofloxacin Derivative-Loaded Nanoparticles Synergize with Paclitaxel Against Type II Human Endometrial Cancer.

Combinations of chemotherapeutic agents comprise a clinically feasible approach to combat cancers that possess resistance to treatment. Type II endometrial cancer is typically associated with poor outcomes and the emergence of chemoresistance. To overcome this challenge, a combination therapy is developed comprising a novel ciprofloxacin derivative-loaded PEGylated polymeric nanoparticles (CIP2b-NPs) and paclitaxel (PTX) against human type-II endometrial cancer (Hec50co with loss of function p53). Cytotoxicity studies reveal strong synergy between CIP2b and PTX against Hec50co, and this is associated with a significant reduction in the IC50 of PTX and increased G2/M arrest. Upon formulation of CIP2b into PEGylated polymeric nanoparticles, tumor accumulation of CIP2b is significantly improved compared to its soluble counterpart; thus, enhancing the overall antitumor activity of CIP2b when co-administered with PTX. In addition, the co-delivery of CIP2b-NPs with paclitaxel results in a significant reduction in tumor progression. Histological examination of vital organs and blood chemistry was normal, confirming the absence of any apparent off-target toxicity. Thus, in a mouse model of human endometrial cancer, the combination of CIP2b-NPs and PTX exhibits superior therapeutic activity in targeting human type-II endometrial cancer.

Anti-melanoma Effects of Resiquimod (RSQ) In Vitro and in Combination with Immune Checkpoint Blockade In Vivo.

Melanoma is the deadliest form of skin cancer and surgery is currently the most effective treatment. However, there are situations where surgery fails or is not an option to treat melanoma patients. Immunotherapy such as immune checkpoint blockade (e.g., anti-PD-1) can be effective as an alternative treatment for melanoma patients; however, the percentage of melanoma patients that exhibit complete responses from anti-PD-1 monotherapy is low, and a hostile immunosuppressive tumor microenvironment may be at least partly responsible. Resiquimod (RSQ) is an imidazoquinolinamine derivative and TLR-7/8 agonist that could enhance the antitumor activity of immune checkpoint blockade when these agents are combined as a treatment for melanoma. Here, the effect of combining systemic anti-PD-1 and locally administered RSQ on the survival of melanoma-challenged mice was tested. Our results demonstrated that anti-PD-1 in combination with RSQ can significantly prolong the survival of melanoma-challenged mice, compared to untreated mice and mice treated with anti-PD-1 alone. In addition, the in vitro studies showed that RSQ can mediate a direct anti-proliferative effect on melanoma cells. In conclusion, the combination of RSQ and anti-PD-1 may be a promising treatment for melanoma patients, especially as both treatments have already been used independently to safely treat melanoma patients.

Heterologous prime-boost vaccine using antigen-loaded microparticles and adenovirus (encoding antigen) enhances cellular immune responses and antitumor activity.

Heterologous prime-boost vaccines have the potential to promote higher immune responses than homologous prime-boost vaccines and were used in this murine study to investigate the effect on the magnitude of the cellular (and humoral) antigen-specific immune responses and antitumor efficacy when a microparticle formulation (prime) is combined with an adenoviral vaccine (boost). Specifically, the prime comprised chick egg ovalbumin (OVA; 25 µg/dose), used here as a model tumor antigen (TA), encapsulated in microparticles (∼700 nm diameter) made from the biodegradable polymer, 50:50 poly(lactic-co-glycolic acid) (PLGA); while attenuated adenovirus (type 5) encoding OVA (Ad5OVA; 108 PFU/dose) was employed as the boost. The ability of OVA-loaded microparticles to enhance OVA-specific antibody responses, OVA-specific CD3 + CD8 + T cell responses and antitumor activity (i.e., protection against OVA-expressing tumor-challenge) to the heterologous prime-boost vaccine was investigated; and it was found that this prime-boost combination could significantly enhance OVA-specific cellular responses compared to all other vaccination groups and was the only group to confer a significant survival advantage over the unvaccinated group (naïve) in a prophylactic animal tumor model. This finding illustrates the potential for combining TA-loaded PLGA-based microparticles with other vaccine formats to improve tumor-specific cellular immune responses.

Investigating silver nanoparticles and resiquimod as a local melanoma treatment.

Over the last decade, the potential for silver nanoparticles (AgNP) to be used as an anti-melanoma agent has been supported by both in vitro and in vivo evidence. However, an undesirably high concentration of AgNP is often required to achieve an antitumor effect. Therefore a combination treatment that can maintain or improve antitumor efficacy (with lower amounts of AgNP) while also reducing off-target effects is sought. In this study, the combination of AgNP and resiquimod (RSQ: a Toll-like receptor agonist) was investigated and shown to significantly prolong the survival of melanoma-challenged mice when added sequentially. Results from toxicity studies showed that the treatment was non-toxic in mice. Immune cell depletion studies suggested the possible involvement of CD8+ T cells in the antitumor response observed in the AgNP + RSQ (sequential) treatment. NanoString was also employed to further understand the mechanism underlying the increase in the treatment efficacy of AgNP + RSQ (sequential); showing significant changes, compared to the naive group, in gene expression in pathways involved in apoptosis and immune stimulation. In conclusion, the combination of AgNP and RSQ is a new combination worthy of further investigation in the context of melanoma treatment.

Topically Applied Resiquimod versus Imiquimod as a Potential Adjuvant in Melanoma Treatment.

Melanoma is the most lethal form of skin cancer and surgery remains the preferred and most effective treatment. Nevertheless, there are cases where surgery is not a viable method and alternative treatments are therefore adopted. One such treatment that has been tested is topical 5% imiquimod (IMQ) cream, which, although showing promise as a treatment for melanoma, has been found to have undesirable off-target effects. Resiquimod (RSQ) is an immunomodulatory molecule that can activate immune responses by binding to Toll-like receptors (TLR) 7 and 8 and may be more effective than IMQ in the context of melanoma treatment. RSQ can cross the stratum corneum (SC) easily without requiring pretreatment of the skin. In a gel formulation, RSQ has been studied as a monotherapy and adjuvant for melanoma treatment in pre-clinical studies and as an adjuvant in clinical settings. Although side effects of RSQ in gel formulation were also reported, they were never severe enough for the treatment to be suspended. In this review, we discuss the potential use of RSQ as an adjuvant for melanoma treatment.

An Intensive Approach to Improving Diversity, Equity, and Inclusion in an Academic Emergency Department.

A healthcare workforce that demonstrates cultural competence and humility while reflecting the diversity of the surrounding community has the potential to significantly benefit the patient population it serves. In this context and given numerous societal influences and the events of 2020, the leadership of the Department of Emergency Medicine at Albany Medical Center recognized the need to promote diversity, equity, and inclusion (DEI) in multiple areas. These included premedical education, medical education, postgraduate medical education, faculty development, staff satisfaction, and patient care. The department formed a DEI taskforce that developed an ongoing, multipronged, interdisciplinary approach to address these important aspects of our work and clinical environment with the goals of improving staff wellbeing, reducing burnout, and promoting the health of our community. Our experience is shared here to illustrate how a small, dedicated team can implement a variety of DEI initiatives quickly and with relatively little cost at a large academic medical center.

Cationic nanoparticles enhance T cell tumor infiltration and antitumor immune responses to a melanoma vaccine.

In clinical settings, cancer vaccines as monotherapies have displayed limited success compared to other cancer immunotherapeutic treatments. Nanoscale formulations have the ability to increase the efficacy of cancer vaccines by combatting the immunosuppressive nature of the tumor microenvironment. Here, we have synthesized a previously unexplored cationic polymeric nanoparticle formulation using polyamidoamine dendrimers and poly(d,l-lactic-co-glycolic acid) that demonstrate adjuvant properties in vivo. Tumor-challenged mice vaccinated with an adenovirus-based cancer vaccine [encoding tumor-associated antigen (TAA)] and subsequently treated with this nanoparticulate formulation showed significant increases in TAA-specific T cells in the peripheral blood, reduced tumor burden, protection against tumor rechallenge, and a significant increase in median survival. An investigation into cell-based pathways suggests that administration of the nanoformulation at the site of the developing tumor may have created an inflammatory environment that attracted activated TAA-specific CD8+ T cells to the vicinity of the tumor, thus enhancing the efficacy of the vaccine.

Preparation and Characterization of a Liver Targeted, Poly(amidoamine) Based, Gene Delivery System.

Nonalcoholic steatohepatitis (NASH) is an aggressive liver disease that is considered a major cause of liver cirrhosis and hepatocellular carcinoma. NASH is characterized by multiple underlying genetic mutations, with no approved cure to date. Gene therapies that target those genetic mutations may play a major role in treating this disease, once delivered specifically to the hepatocytes. In this chapter we present, in detail, the synthesis and the characterization of an efficient gene delivery system capable of targeting hepatocytes by exploiting the overexpression of asialoglycoprotein receptors on their cell surface. The targeting ligand, galactose derivative, lactobionic acid (Gal), is first conjugated to bifunctional poly(ethylene glycol) (PEG), and then the formed PEG-Gal is further conjugated to the positively charged polymer, poly(amidoamine) (PAMAM) to form a PAMAM-PEG-Gal construct that can complex and deliver genetic material (e.g., pDNA, siRNA, mRNA) specifically to hepatocytes. We first synthesize PAMAM-PEG-Gal using carbodiimide click chemistry. The synthesized conjugate is characterized using 1H NMR spectroscopy and mass spectrometry. Next, nanoplexes are prepared by combining the positively charged conjugate and the negatively charged genetic material at different nitrogen to phosphate (N/P) ratios; then the size, charge, electrophoretic mobility, and surface morphology of those nanoplexes are estimated. The simplicity of complexing our conjugate with any type of genetic material, the ability of our delivery system to overcome the current limitations of delivering naked genetic material, and the efficiency of delivering its payload specifically to hepatocytes, makes our formulation a promising tool to treat any type of genetic abnormality that arises in hepatocytes, and specifically NASH.

Potential Role of Selenium in the Treatment of Cancer and Viral Infections.

Selenium has been extensively evaluated clinically as a chemopreventive agent with variable results depending on the type and dose of selenium used. Selenium species are now being therapeutically evaluated as modulators of drug responses rather than as directly cytotoxic agents. In addition, recent data suggest an association between selenium base-line levels in blood and survival of patients with COVID-19. The major focus of this mini review was to summarize: the pathways of selenium metabolism; the results of selenium-based chemopreventive clinical trials; the potential for using selenium metabolites as therapeutic modulators of drug responses in cancer (clear-cell renal-cell carcinoma (ccRCC) in particular); and selenium usage alone or in combination with vaccines in the treatment of patients with COVID-19. Critical therapeutic targets and the potential role of different selenium species, doses, and schedules are discussed.

The MEK 1/2 inhibitor PD98059 exhibits synergistic anti-endometrial cancer activity with paclitaxel in vitro and enhanced tissue distribution in vivo when formulated into PAMAM-coated PLGA-PEG nanoparticles.

Endometrial cancer is the most common gynecological cancer that affects the female reproductive organs. The standard therapy for EC for the past two decades has been chemotherapy and/or radiotherapy. PD98059 is a reversible MEK inhibitor that was found in these studies to increase the cytotoxicity of paclitaxel (PTX) against human endometrial cancer cells (Hec50co) in a synergistic and dose-dependent manner. Additionally, while PD98059 arrested Hec50co cells at the G0/G1 phase, and PTX increased accumulation of cells at the G2/M phase, the combination treatment increased accumulation at both the G0/G1 and G2/M phases at low PTX concentrations. We recently developed poly(lactide-co-glycolide) (PLGA) nanoparticles (NPs) modified with polyethylene glycol (PEG) and coated with polyamidoamine (PAMAM) (referred to here as PGM NPs) which have favorable biodistribution profiles in mice, compared to PD98059 solution. Here, in order to enhance tissue distribution of PD98059, PD98059-loaded PGM NPs were prepared and characterized. The average size, zeta potential, and % encapsulation efficiency (%EE) of these NPs was approximately 184 nm, + 18 mV, and 23%, respectively. The PD98059-loaded PGM NPs released ~ 25% of the total load within 3 days in vitro. In vivo murine studies revealed that the pharmacokinetics and biodistribution profile of intravenous (IV) injected PD98059 was improved when delivered as PD98059-loaded PGM NPs as opposed to soluble PD98059. Further investigation of the in vivo efficacy and safety of this formulation is expected to emphasize the potential of its clinical application in combination with commercial PTX formulations against different cancers.

Thiophene derivative-loaded nanoparticles mediate anticancer activity through the inhibition of kinases and microtubule assembly.

Different tetrahydrobenzo[b]thiophene derivatives were explored as new tubulin polymerization destabilizers to arrest tumor cell mitosis. A series of compounds incorporating the tetrahydrobenzo[b]thiophene scaffold were synthesized, and their biological activities were investigated. The cytotoxicity of each of the synthesized compounds was assessed against a range of cell lines. Specifically, the benzyl urea tetrahydrobenzo[b]thiophene derivative, 1-benzyl-3-(3-cyano-4,5,6,7-tetrahydrobenzo[b]thiophen-2-yl)urea (BU17), was identified as the most potent compound with broad-spectrum antitumor activity against several cancer cell lines. The potential mechanism(s) of action were investigated where dose-dependent G2/M accumulation and A549 cell cycle arrest were detected. Additionally, A549 cells treated with BU17 expressed enhanced levels of caspase 3 and 9, indicating the induction of apoptosis. Furthermore, it was found that BU17 inhibits WEE1 kinase and targets tubulin by blocking its polymerization. BU17 was also formulated into PLGA nanoparticles, and it was demonstrated that BU17-loaded nanoparticles could significantly enhance antitumor activity compared to the soluble counterpart.

Enhancement of Therapies for Glioblastoma (GBM) Using Nanoparticle-based Delivery Systems.

Glioblastoma multiforme (GBM) is the most aggressive type of malignant brain tumor. Current FDA-approved treatments include surgical resection, radiation, and chemotherapy, while hyperthermia, immunotherapy, and most relevantly, nanoparticle (NP)-mediated delivery systems or combinations thereof have shown promise in preclinical studies. Drug-carrying NPs are a promising approach to brain delivery as a result of their potential to facilitate the crossing of the blood-brain barrier (BBB) via two main types of transcytosis mechanisms: adsorptive-mediated transcytosis (AMT) and receptor-mediated transcytosis (RMT). Their ability to accumulate in the brain can thus provide local sustained release of tumoricidal drugs at or near the site of GBM tumors. NP-based drug delivery has the potential to significantly reduce drug-related toxicity, increase specificity, and consequently improve the lifespan and quality of life of patients with GBM. Due to significant advances in the understanding of the molecular etiology and pathology of GBM, the efficacy of drugs loaded into vectors targeting this disease has increased in both preclinical and clinical settings. Multitargeting NPs, such as those incorporating multiple specific targeting ligands, are an innovative technology that can lead to decreased off-target effects while simultaneously having increased accumulation and action specifically at the tumor site. Targeting ligands can include antibodies, or fragments thereof, and peptides or small molecules, which can result in a more controlled drug delivery system compared to conventional drug treatments. This review focuses on GBM treatment strategies, summarizing current options and providing a detailed account of preclinical findings with prospective NP-based approaches aimed at improving tumor targeting and enhancing therapeutic outcomes for GBM patients.

Skin Penetration Enhancement Strategies Used in the Development of Melanoma Topical Treatments.

Malignant melanoma is an aggressive form of skin cancer for which there is currently no reliable therapy and is considered one of the leading health issues in the USA. At present, surgery is the most effective and acceptable treatment; however, surgical excision can be impractical in certain circumstances. Topical skin delivery of drugs using topical formulations is a potential alternative approach which can have many advantages aside from being a non-invasive delivery route. Nevertheless, the presence of the stratum corneum (SC) limits the penetration of drugs through the skin, lowering their treatment efficacy and raising concerns among physicians and patients as to their effectiveness. Currently, research groups are trying to circumvent the SC barrier by using skin penetration enhancement (SPE) strategies. The SPE strategies investigated include chemical skin penetration enhancers (CPEs), physical skin penetration enhancers (PPEs), nanocarrier systems, and a combination of SPE strategies (cream). Of these, PPEs and cream are the most advanced approaches in terms of preclinical and clinical studies, respectively.

A Novel, Low-cost, Low-fidelity Pericardiocentesis Teaching Model.

INTRODUCTION: Pericardiocentesis is a high-risk/low-frequency procedure important to emergency medicine (EM). However, due to case rarity it is not often performed on a patient during residency training. Because the coronavirus disease 2019 pandemic limited cadaver-based practice, we developed a novel, low-cost, low-fidelity pericardiocentesis model using three dimensional-printing technology to provide advances on prior home-made models. METHODS: Residents watched a 20-minute video about performing a pericardiocentesis and practiced both a blind and ultrasound-guided technique. We assessed model fidelity, convenience, and perceived provider competence via post-workshop questionnaire. RESULTS: A total of 24/26 (93%) individuals practicing on the ultrasound-guided model and 22/24 (92%) on the blind approach model agreed or strongly agreed that the models reasonably mimicked a pericardial effusion. CONCLUSION: Our low-cost, low-fidelity model is durable, mimics the clinical case, and is easy to use. It also addresses known limitations from prior low-fidelity models.

Evolution of drug-eluting biomedical implants for sustained drug delivery.

In the field of drug delivery, the most commonly used treatments have traditionally been systemically delivered using oral or intravenous administration. The problems associated with this type of delivery is that the drug concentration is controlled by first pass metabolism, and therefore may not always remain within the therapeutic window. Implantable drug delivery systems (IDDSs) are an excellent alternative to traditional delivery because they offer the ability to precisely control the drug release, deliver drugs locally to the target tissue, and avoid the toxic side effects often experienced with systemic administration. Since the creation of the first FDA-approved IDDS in 1990, there has been a surge in research devoted to fabricating and testing novel IDDS formulations. The versatility of these systems is evident when looking at the various biomedical applications that utilize IDDSs. This review provides an overview of the history of IDDSs, with examples of the different types of IDDS formulations, as well as looking at current and future biomedical applications for such systems. Though there are still obstacles that need to be overcome, ever-emerging new technologies are making the manufacturing of IDDSs a rewarding therapeutic endeavor with potential for further improvements.

Cyclohepta[b]thiophenes as Potential Antiproliferative Agents: Design, Synthesis, In Vitro, and In Vivo Anticancer Evaluation.

Several thiophene featuring compounds are known for their promising antiproliferative activity. Prompted by the urgent need to identify new potent anticancer agents, 16 compounds of benzamides, benzylamines, and urea analogues incorporating a cyclohepta[b]thiophene scaffold were synthesized and biologically evaluated with a cell proliferation assay using the A549 nonsmall cell lung cancer cell line. Compound 17 demonstrated both potent and broad-spectrum anticancer activity with submicromolar 50% growth inhibition (GI50) values. It also showed superior antiproliferative activity (vs nocodazole) in OVACAR-4, OVACAR-5, CAKI-1, and T47D cell lines with GI50 values of 2.01 (vs 22.28), 2.27 (vs 20.75), 0.69 (vs 1.11), and 0.362 (vs 81.283) µM, respectively. Additionally, compound 17 displayed minimal cytotoxicity based on 50% lethal concentration (LC50) values toward all tested cell lines. Further cell-based mechanistic studies of compound 17 revealed its ability to induce cell cycle arrest of A549 cells as evidenced by dose dependent G2/M accumulation. Furthermore, induction of early apoptosis along with activation of caspase 3, 8, and 9 were confirmed in A549 cells treated with compound 17. Targeting tubulin polymerization may explain the mechanism of the antiproliferative activity of compound 17 based on cell cycle analysis, detected apoptosis, and in vitro inhibition of tubulin polymerization. In vitro data were further supported by in vivo antitumor efficacy studies of compound 17 in a CT26 murine model for which the results showed a reduction in the tumor growth compared to untreated mice. Overall, compound 17 has the potential to function as a promising candidate for further development of potent anticancer chemotherapeutics.

A Case of Hyperkalemia Versus Pseudohyperkalemia in Chronic Lymphocytic Leukemia.

INTRODUCTION: Both hyperkalemia and pseudohyperkalemia occur in the emergency department. True hyperkalemia necessitates emergent treatment while pseudohyperkalemia requires recognition to prevent inappropriate treatment. It is imperative that the emergency physician (EP) have an understanding of the causes and clinical presentations of both phenomena. CASE REPORT: We present a case of an 88-year-old male with chronic lymphocytic leukemia (CLL) and suspected blast crisis who was found to have elevated serum potassium levels without other manifestations of hyperkalemia and eventually was determined to have pseudohyperkalemia due to white cell fragility. DISCUSSION: Differentiation of hyperkalemia and pseudohyperkalemia is a critical skill for the EP. We discuss multiple causes of hyperkalemia and pseudohyperkalemia in an effort to broaden the knowledge base. CONCLUSION: We present a case of CLL as an unusual cause of pseudohyperkalemia and review common causes of pseudohyperkalemia.

Poly(diaminosulfide) Microparticle-Based Vaccine for Delivery of Leptospiral Antigens.

Leptospirosis is a debilitating infectious disease that detrimentally affects both animals and humans; therefore, disease prevention has become a high priority to avoid high incidence rates of disease in the herd and break the transmission cycle to humans. Thus, there remains an important unmet need for a prophylactic vaccine that can provide long-term immunity against leptospirosis in cattle. Herein, a novel vaccine formulation was developed where poly(diaminosulfide) polymer was employed to fabricate microparticles encapsulating the antigen of Leptospira borgpetersenii serovar Hardjo strain HB15B203 (L203-PNSN). A prime-boost vaccination with a L203-PNSN microparticle formulation increased the population of L203-specific CD3+ T cells and CD21+ B cells to levels that were significantly higher than those of cattle vaccinated with L203-AlOH or the vehicle control (empty PNSN microparticles and blank AlOH). In addition, L203-PNSN was demonstrated to stimulate durable humoral immune responses as evidenced by the increases in the antibody serum titers following the vaccination. It was also found that cattle vaccinated with L203-PNSN produced higher macroscopic agglutinating titers than cattle in other groups. Thus, it can be concluded that L203-PNSN is a novel first-in-class microparticle-based Leptospira vaccine that represents a powerful platform with the potential to serve as a prophylactic vaccine against leptospiral infection in cattle.