The Digital Therapeutics Real-World Evidence Framework: An Approach for Guiding Evidence-Based Digital Therapeutics Design, Development, Testing, and Monitoring.

Digital therapeutics (DTx) are a promising way to provide safe, effective, accessible, sustainable, scalable, and equitable approaches to advance individual and population health. However, developing and deploying DTx is inherently complex in that DTx includes multiple interacting components, such as tools to support activities like medication adherence, health behavior goal-setting or self-monitoring, and algorithms that adapt the provision of these according to individual needs that may change over time. While myriad frameworks exist for different phases of DTx development, no single framework exists to guide evidence production for DTx across its full life cycle, from initial DTx development to long-term use. To fill this gap, we propose the DTx real-world evidence (RWE) framework as a pragmatic, iterative, milestone-driven approach for developing DTx. The DTx RWE framework is derived from the 4-phase development model used for behavioral interventions, but it includes key adaptations that are specific to the unique characteristics of DTx. To ensure the highest level of fidelity to the needs of users, the framework also incorporates real-world data (RWD) across the entire life cycle of DTx development and use. The DTx RWE framework is intended for any group interested in developing and deploying DTx in real-world contexts, including those in industry, health care, public health, and academia. Moreover, entities that fund research that supports the development of DTx and agencies that regulate DTx might find the DTx RWE framework useful as they endeavor to improve how DTxcan advance individual and population health.

Inequities in PrEP use according to Medicare status in a publicly funded sexual health clinic; a retrospective analysis.

New HIV diagnoses continue to disproportionately affect overseas-born men who have sex with men (MSM). A retrospective study of all pre-exposure prophylaxis (PrEP)-eligible MSM attending Sydney Sexual Health Centre for the first time in 2021 analysed self-reported PrEP-use, PrEP prescribed at the initial consult, and PrEP taken during 2021 using binomial logistic regression models. A total of 1367 clients were included in the analysis, 716 (52.4%) were born overseas and 414 (57.8%) were Medicare-ineligible. Medicare-ineligible clients were less likely to be on PrEP at initial visit (OR 0.45, 95% CI 0.26-0.77). This study suggests inequities in PrEP access and/or awareness in Medicare-ineligible MSM in Australia.

Imagining, designing, and interpreting experiments: Using quantitative assessment to improve instruction in scientific reasoning.

Effectively teaching scientific reasoning requires an understanding of the challenges students face when learning these skills. We designed an assessment that measures undergraduate student abilities to form hypotheses, design experiments, and interpret data from experiments in cellular and molecular biology. The assessment uses intermediate-constraint free-response questions with a defined rubric to facilitate use with large classes, while identifying common reasoning errors that may prevent students from becoming proficient at designing and interpreting experiments. The assessment measured a statistically significant improvement in a senior-level biochemistry laboratory course, and a larger improvement between the biochemistry lab students and a separate cohort in a first-year introductory biology lab course. Two common errors were identified for forming hypotheses and using experimental controls. Students frequently constructed a hypothesis that was a restatement of the observation it was supposed to explain. They also often made comparisons to control conditions not included in an experiment. Both errors were most frequent among first-year students, and decreased in frequency as students completed the senior-level biochemistry lab. Further investigation of the absent controls error indicated that difficulties with reasoning about experimental controls may be widespread in undergraduate students. The assessment was a useful instrument for measuring improvement in scientific reasoning at different levels of instruction, and identified errors that can be targeted to improve instruction in the process of science.

A Faster Prostate MRI: Comparing a Novel Denoised, Single-Average T2 Sequence to the Conventional Multiaverage T2 Sequence Regarding Lesion Detection and PI-RADS Score Assessment.

BACKGROUND: The T2 w sequence is a standard component of a prostate MRI examination; however, it is time-consuming, requiring multiple signal averages to achieve acceptable image quality. PURPOSE/HYPOTHESIS: To determine whether a denoised, single-average T2 sequence (T2 -R) is noninferior to the standard multiaverage T2 sequence (T2 -S) in terms of lesion detection and PI-RADS score assessment. STUDY TYPE: Retrospective. POPULATION: A total of 45 males (age range 60-75 years) who underwent clinically indicated prostate MRI examinations, 21 of whom had pathologically proven prostate cancer. FIELD STRENGTH/SEQUENCE: A 3 T; T2 w FSE, DWI with ADC maps, and dynamic contrast-enhanced images with color-coded perfusion maps. T2 -R images were created from the raw data utilizing a single "average" with iterative denoising. ASSESSMENT: Nine readers randomly assessed complete exams including T2 -R and T2 -S images in separate sessions. PI-RADS version 2.1 was used. All readers then compared the T2 -R and T2 -S images side by side to evaluate subjective preference. An additional detailed image quality assessment was performed by three senior level readers. STATISTICAL TESTS: Generalized linear mixed effects models for differences in lesion detection, image quality features, and overall preference between T2 -R and T2 -S sequences. Intraclass correlation coefficients (ICC) were used to assess reader agreement for all comparisons. A significance threshold of P = 0.05 was used for all statistical tests. RESULTS: There was no significant difference between sequences regarding identification of lesions with PI-RADS ≥3 (P = 0.10) or PI-RADS score (P = 0.77). Reader agreement was excellent for lesion identification (ICC = 0.84). There was no significant overall preference between the two sequences regarding image quality (P = 0.07, 95% CI: [-0.23, 0.01]). Reader agreement was good regarding sequence preference (ICC = 0.62). DATA CONCLUSION: Use of single-average, denoised T2 -weighted images was noninferior in prostate lesion detection or PI-RADS scoring when compared to standard multiaverage T2 -weighted images. EVIDENCE LEVEL: 3. TECHNICAL EFFICACY: Stage 3.

Social Mobile Approaches to Reducing Weight (SMART) 2.0: protocol of a randomized controlled trial among young adults in university settings.

BACKGROUND: Excess weight gain in young adulthood is associated with future weight gain and increased risk of chronic disease. Although multimodal, technology-based weight-loss interventions have the potential to promote weight loss among young adults, many interventions have limited personalization, and few have been deployed and evaluated for longer than a year. We aim to assess the effects of a highly personalized, 2-year intervention that uses popular mobile and social technologies to promote weight loss among young adults. METHODS: The Social Mobile Approaches to Reducing Weight (SMART) 2.0 Study is a 24-month parallel-group randomized controlled trial that will include 642 overweight or obese participants, aged 18-35 years, from universities and community colleges in San Diego, CA. All participants receive a wearable activity tracker, connected scale, and corresponding app. Participants randomized to one intervention group receive evidence-based information about weight loss and behavior change techniques via personalized daily text messaging (i.e., SMS/MMS), posts on social media platforms, and online groups. Participants in a second intervention group receive the aforementioned elements in addition to brief, technology-mediated health coaching. Participants in the control group receive a wearable activity tracker, connected scale, and corresponding app alone. The primary outcome is objectively measured weight in kilograms over 24 months. Secondary outcomes include anthropometric measurements; physiological measures; physical activity, diet, sleep, and psychosocial measures; and engagement with intervention modalities. Outcomes are assessed at baseline and 6, 12, 18, and 24 months. Differences between the randomized groups will be analyzed using a mixed model of repeated measures and will be based on the intent-to-treat principle. DISCUSSION: We hypothesize that both SMART 2.0 intervention groups will significantly improve weight loss compared to the control group, and the group receiving health coaching will experience the greatest improvement. We further hypothesize that differences in secondary outcomes will favor the intervention groups. There is a critical need to advance understanding of the effectiveness of multimodal, technology-based weight-loss interventions that have the potential for long-term effects and widespread dissemination among young adults. Our findings should inform the implementation of low-cost and scalable interventions for weight loss and risk-reducing health behaviors. TRIAL REGISTRATION: ClinicalTrials.gov NCT03907462 . Registered on April 9, 2019.

Young Australians' experiences of sexual healthcare provision by general practitioners.

BACKGROUND AND OBJECTIVES: Young Australians are disproportionately affected by sexually transmissible infections (STIs), compared with the general population. The aim of this study was to explore how young Australians sought sexual healthcare from their general practitioners (GPs) and what factors were important to them when seeking sexual healthcare. METHOD: A cross-sectional study was performed using an anonymous survey of young people. RESULTS: Those belonging to a priority population were less likely to seek sexual healthcare from their GPs when compared with the non-priority population. Those not belonging to a priority population but with a history of ≥1 STI were also less likely to seek sexual healthcare from their GPs when compared with the rest of the non-priority population. DISCUSSION: Young people with a history of ≥1 STI who do not belong to a priority population may be avoiding their GPs for sexual healthcare. This group of young people is at risk of STIs, and research is needed to determine how to best provide adequate sexual healthcare for this population.

Comparing DNA methylation profiles in saliva and intestinal mucosa.

BACKGROUND: Altered epigenetic profiles are a feature of intestinal diseases, including ulcerative colitis and Crohn's disease. DNA methylation studies in these diseases have utilised intestinal mucosal tissue or blood which can be difficult to collect, particularly for large-scale research studies. Saliva is an attractive alternative for epigenetic studies as it is easy to collect and provides high quality methylation profiles. The aim of the study was to determine the utility of saliva as an alternative for DNA methylation studies of intestinal disorders. RESULTS: DNA methylation in saliva and intestinal mucosa samples were compared in individuals (n = 10) undergoing endoscopies using the Illumina Infinium Methylation 450 K Beadchip array. We found that DNA methylation was correlated between tissue types within an individual (Pearson correlation co-efficient r = 0.92 to 0.95, p < 0.001). Of the 48,541 probes (approximately 11% of CpG sites) that were differentially methylated between saliva and intestinal mucosa (adjusted p < 0.001, |Δß| ≥ 20%), these mapped to genes involved in tissue-specific pathways, including the apelin signalling and oxytocin pathways which are important in gastrointestinal cytoprotection and motility. CONCLUSIONS: This study suggests that saliva has the potential to be used as an alternate DNA source to invasive intestinal mucosa for DNA methylation research into intestinal conditions.

Advanced Imaging for the Diagnosis and Treatment of Coexistent Renal and Müllerian Abnormalities.

PURPOSE OF REVIEW: Abnormal development of the uterus, cervix, and proximal 2/3 of the vagina results in Müllerian duct anomalies. Because of the close embryologic relationship between the developing female genital and urinary tracts, abnormalities of the urinary tract often accompany Müllerian duct anomalies. Magnetic resonance imaging (MRI) is the current gold standard-imaging modality in the evaluation of the anomalies of the female reproductive tract. This article discusses the imaging evaluation of Müllerian duct and accompanying urinary tract anomalies with a particular focus on the MRI findings. RECENT FINDINGS: Several studies have shown high concordance between MRI and three-dimensional ultrasound (3D US) in the evaluation of Müllerian duct abnormalities. 3D US is more cost effective than MRI but has not yet been fully substantiated as a comparable modality to MRI. Additionally, 3D US does not help elucidate concomitant anomalies of the urologic system. Müllerian duct anomalies are often associated with abnormalities of the urinary tract. Evaluation with MRI is important for the diagnosis of Müllerian duct anomalies and also helps with potential surgical planning.

Battle of the Bacteria: Characterizing the Evolutionary Advantage of Stationary Phase Growth.

Providing students with authentic research opportunities has been shown to enhance learning and increase retention in STEM majors. Accordingly, we have developed a novel microbiology lab module, which focuses on the molecular mechanisms of evolution in E. coli, by examining the growth advantage in stationary phase (GASP) phenotype. The GASP phenotype is demonstrated by growing cells into long-term stationary phase (LTSP) and then competing them against un-aged cells in a fresh culture. This module includes learning goals related to strengthening practical laboratory skills and improving student understanding of evolution. In addition, the students generate novel data regarding the effects of different environmental stresses on GASP and the relationship between evolution, genotypic change, mutation frequency, and cell stress. Pairs of students are provided with the experimental background, select a specific aspect of the growth medium to modify, and generate a hypothesis regarding how this alteration will impact the GASP phenotype. From this module, we have demonstrated that students are able to achieve the established learning goals and have produced data that has furthered our understanding of the GASP phenotype. Journal of Microbiology & Biology Education.

Correlation, necessity, and sufficiency: Common errors in the scientific reasoning of undergraduate students for interpreting experiments.

Gaining an understanding of how science works is central to an undergraduate education in biology and biochemistry. The reasoning required to design or interpret experiments that ask specific questions does not come naturally, and is an essential part of the science process skills that must be learned for an understanding of how scientists conduct research. Gaps in these reasoning skills make it difficult for students to become proficient in reading primary scientific literature. In this study, we assessed the ability of students in an upper-division biochemistry laboratory class to use the concepts of correlation, necessity, and sufficiency in interpreting experiments presented in a format and context that is similar to what they would encounter when reading a journal article. The students were assessed before and after completion of a laboratory module where necessary vs. sufficient reasoning was used to design and interpret experiments. The assessment identified two types of errors that were commonly committed by students when interpreting experimental data. When presented with an experiment that only establishes a correlation between a potential intermediate and a known effect, students frequently interpreted the intermediate as being sufficient (causative) for the effect. Also, when presented with an experiment that tests only necessity for an intermediate, they frequently made unsupported conclusions about sufficiency, and vice versa. Completion of the laboratory module and instruction in necessary vs. sufficient reasoning showed some promise for addressing these common errors.

New ideas for an old enzyme: A short, question-based laboratory project for the purification and identification of an unknown LDH isozyme.

Enzyme purification projects are an excellent way to introduce many aspects of protein biochemistry, but can be difficult to carry out under the constraints of a typical undergraduate laboratory course. We have designed a short laboratory project for the purification and identification of an "unknown" lactate dehydrogenase (LDH) isozyme that can fit into a multiproject course without consuming too many laboratory days. The streamlined purification utilizes ammonium sulfate precipitation, affinity chromatography, and size exclusion chromatography to give good recovery of LDH with minimal equipment requirements, and can be completed in three laboratory periods of 3-4 hours. As part of this, we have designed a novel, qualitative format for an LDH activity assay that allows students to rapidly screen their column chromatography fractions without the need of a spectrophotometer or plate reader. The analysis phase of the project is question-driven, and can be completed in two laboratory periods. The students must determine which purification technique was most effective by quantifying LDH activity and total protein content at each step of the purification, and then identify their unknown isozyme through agarose gel electrophoresis. This module provides an engaging format for teaching protein biochemistry, with the flexibility to allow an instructor to modify it for their particular curriculum.

Positive and negative regulation of cellular sensitivity to anti-cancer drugs by FGF-2.

The development of resistance to chemotherapy by tumor cells remains a constant limitation to the treatment of cancer. Over the last several years, fibroblast growth factor-2 (FGF-2) has emerged as a growth factor that is capable of modifying the sensitivity of normal and tumor cells to anti-cancer drugs. FGF-2 can produce both drug resistance and drug sensitization in different cell types treated with a variety of cytotoxic agents. An understanding of the differential cellular trafficking and biological activities of the multiple FGF-2 isoforms will help in determining the circumstances under which FGF-2 acts to inhibit versus potentiate drug action. Recent advances suggest that expression of FGF-2 in tumor cells is involved with loss of response to chemotherapy in vivo. Thus, the manipulation of FGF-2 activities to increase the effectiveness of chemotherapeutic agents may have important clinical implications.

Chemosensitization by fibroblast growth factor-2 is not dependent upon proliferation, S-phase accumulation, or p53 status.

Fibroblast growth factor-2 (bFGF/FGF-2) is a pleiotropic growth factor that functions as a survival factor and directs apoptosis during embryogenesis and development. As a survival factor, FGF-2 would be expected to protect cells against drug toxicities. Such protection has been reported in some cells treated with some chemotherapeutic drugs. However, we recently demonstrated that FGF-2 can sensitize NIH 3T3 mouse fibroblasts to the cytotoxic and apoptotic effects of cisplatin. Sensitization requires prolonged incubation of cells with FGF-2 before the addition of cisplatin, and it requires an FGF-2 concentration (5-10 ng/mL) that is higher than that needed for its mitogenic effects (0.5 ng/mL). We now report that FGF-2 can also sensitize MCF7 human breast cancer cells and A2780 human ovarian cancer cells, as well as NIH 3T3 cells, to cisplatin. FGF-2 did not affect the cisplatin sensitivity of SKOV3 ovarian cancer cells or a panel of seven pancreatic cancer cell lines. We have demonstrated that the sensitizing effect is not simply a function of the mitogenic activity of FGF-2 on cells, as we did not observe sensitization with other growth-stimulatory factors (FGF-1 and epidermal growth factor); the sensitizing effect of FGF-2 was observed even with cell lines that were not growth-stimulated by FGF-2; and sensitization was not restricted to cells in S-phase of the cell cycle. These results indicate that cell proliferation is neither necessary nor sufficient for sensitization by FGF-2. Moreover, sensitization to cisplatin appears to be p53-independent, as p53-null 3T3 10-1 cells were equally sensitized by FGF-2. Finally, FGF-2 also sensitized NIH 3T3 and MCF7 cells to carboplatin, and had smaller effects on the sensitivity of these cell lines to doxorubicin and docetaxel. FGF-2 had no effect on sensitivity to etoposide in any cell line tested. Therefore, sensitization by FGF-2 was most effective with the platinum compounds, suggesting that this activity may be specific to particular mechanisms of drug action.

Liposomal daunorubicin overcomes drug resistance in human breast, ovarian and lung carcinoma cells.

Multi-drug resistance due in part to membrane pumps such as P-glycoprotein (Pgp) is a major clinical problem in human cancers. We tested the ability of liposomally-encapsulated daunorubicin (DR) to overcome resistance to this drug. A widely used breast carcinoma cell line originally selected for resistance in doxorubicin (MCF7ADR) was 4-fold resistant to DR compared to the parent MCF7 cells (IC50 79 nM vs. 20 nM). Ovarian carcinoma cells (SKOV3) were made resistant by retroviral transduction of MDR1 cDNA and selection in vinblastine. The resulting SKOV3MGP1 cells were 130-fold resistant to DR compared to parent cells (IC50 5700 nM vs. 44 nM). Small-cell lung carcinoma cells (H69VP) originally selected for resistance to etoposide were 6-fold resistant to DR compared to H69 parent cells (IC50 180 nM vs. 30 nM). In all three cases, encapsulation of DR in liposomes as Daunoxome (Gilead) did not change the IC50 of parent cells relative to free DR. However, liposomal DR overcame resistance in MCF7ADR breast carcinoma cells (IC50 20 nM), SKOV3MGP1 ovarian carcinoma cells (IC50 237 nM) and H69VP small-cell lung carcinoma cells (IC50 27 nM). Empty liposomes did not affect the IC50 for free DR in the three resistant cell lines, nor did empty liposomes affect the IC50 for other drugs that are part of the multi-drug resistance phenotype (etoposide, vincristine) in lung carcinoma cells. These data indicate the possible value of liposomal DR in overcoming Pgp-mediated drug resistance in human cancer.