Nonpathogenic E. coli engineered to surface display cytokines as a new platform for immunotherapy.

Given the safety, tumor tropism, and ease of genetic manipulation in non-pathogenic Escherichia coli (E. coli), we designed a novel approach to deliver biologics to overcome poor trafficking and exhaustion of immune cells in the tumor microenvironment, via the surface display of key immune-activating cytokines on the outer membrane of E. coli K-12 DH5α. Bacteria expressing murine decoy-resistant IL18 mutein (DR18) induced robust CD8+ T and NK cell-dependent immune responses leading to dramatic tumor control, extending survival, and curing a significant proportion of immune-competent mice with colorectal carcinoma and melanoma. The engineered bacteria demonstrated tumor tropism, while the abscopal and recall responses suggested epitope spreading and induction of immunologic memory. E. coli K-12 DH5α engineered to display human DR18 potently activated mesothelin-targeting CAR NK cells and safely enhanced their trafficking into the tumors, leading to improved control and survival in xenograft mice bearing mesothelioma tumor cells, otherwise resistant to NK cells. Gene expression analysis of the bacteria-primed CAR NK cells showed enhanced TNFα signaling via NFkB and upregulation of multiple activation markers. Our novel live bacteria-based immunotherapeutic platform safely and effectively induces potent anti-tumor responses in otherwise hard-to-treat solid tumors, motivating further evaluation of this approach in the clinic.

Academic-Practice Partnership to Strengthen Nursing Care of Older Adults.

A long-standing academic-practice partnership was leveraged to facilitate student learning opportunities pertaining to care provision for older adults living with multiple chronic conditions and complex medical problems. Students from a gerontological nursing course in an accelerated baccalaureate nursing program were partnered with gerontology-educated population health nurses in primary care settings. Students observed how population health nurses integrated the Institute for Healthcare Improvement Age-Friendly 4Ms framework into clinical practice as they performed behavioral, psychosocial, and biometric health risks assessments for older adults during their Medicare annual wellness visit. The population health nurses served as role models for professional delivery of age-friendly care including preventative health and wellness care. Student confidence and perception of their understanding of age-friendly and gerontological nursing care improved. Post clinical experience debrief sessions and clinical reflection assignments demonstrated students' admiration of the expansive role and person-centered approach that population health nurses undertake to ensure comprehensive assessment and wellness promotion. Students appreciated the fluidity of population health nurses' conversation regarding the things that matter most to older adults with complex medical conditions.

Mirvetuximab soravtansine for platinum-resistant epithelial ovarian cancer.

INTRODUCTION: Mirvetuximab soravtansine (mirvetuximab) is an antibody drug conjugate (ADC) comprised of a humanized folate receptor alpha (FRα)-binding monoclonal antibody attached via a cleavable linker to the cytotoxic maytansinoid molecule, DM4. FRα is expressed in several epithelial cancers, including high grade serous ovarian cancer (HGSOC). Mirvetuximab received accelerated approval by the United States Food and Drug Administration (FDA) in November 2022 based on the results of the SORAYA trial, which tested mirvetuximab for the treatment of patients with recurrent platinum resistant HGSOC with high FRα expression and showed an overall response rate (ORR) of 32.4% and a median duration of response of 6.9 months. Mirvetuximab toxicities included low grade ocular and gastrointestinal toxicities. The National Comprehensive Cancer Network (NCCN) ovarian cancer 2023 guidelines adopted mirvetuximab as 2A, and mirvetuximab combined with bevacizumab as 2B, recommendations. AREAS COVERED: This manuscript will review the preclinical and clinical development of mirvetuximab, the toxicities associated with mirvetuximab and mitigation strategies, and future applications of mirvetuximab. EXPERT OPINION: Mirvetuximab represents the first biomarker-directed therapy with an indication specifically for the treatment of PROC. The efficacy and favorable safety profile support further development of mirvetuximab and mirvetuximab combinations in platinum sensitive and newly diagnosed ovarian cancer.

Satellite repeat RNA expression in epithelial ovarian cancer associates with a tumor-immunosuppressive phenotype.

Aberrant expression of viral-like repeat elements is a common feature of epithelial cancers, and the substantial diversity of repeat species provides a distinct view of the cancer transcriptome. Repeatome profiling across ovarian, pancreatic, and colorectal cell lines identifies distinct clustering independent of tissue origin that is seen with coding gene analysis. Deeper analysis of ovarian cancer cell lines demonstrated that human satellite II (HSATII) satellite repeat expression was highly associated with epithelial-mesenchymal transition (EMT) and anticorrelated with IFN-response genes indicative of a more aggressive phenotype. SATII expression - and its correlation with EMT and anticorrelation with IFN-response genes - was also found in ovarian cancer RNA-Seq data and was associated with significantly shorter survival in a second independent cohort of patients with ovarian cancer. Repeat RNAs were enriched in tumor-derived extracellular vesicles capable of stimulating monocyte-derived macrophages, demonstrating a mechanism that alters the tumor microenvironment with these viral-like sequences. Targeting of HSATII with antisense locked nucleic acids stimulated IFN response and induced MHC I expression in ovarian cancer cell lines, highlighting a potential strategy of modulating the repeatome to reestablish antitumor cell immune surveillance.

Immunotherapy for ovarian cancer.

Epithelial ovarian cancer (EOC) is the most lethal gynecologic malignancy, with poor survival rates among patients who have advanced disease despite recent significant advances in therapy, including therapy targeting the homologous recombination pathway. Evidence that cell-mediated antitumor immunity, as well as documented programmed death ligand 1 expression, is correlated with improved survival in EOC garnered early optimism regarding the utility of immune checkpoint blockade (ICB) in ovarian cancer. However, the results of multiple clinical trials investigating ICB have revealed very low levels of activity of single-agent immune checkpoint inhibitors, and the testing of combination therapies has not yet identified any combinations with robust activity in a significant proportion of patients who have EOC. In this review, we summarize the results of the major studies of ICB monotherapy and combinations; review novel combinations under investigation, including ICB with cellular therapies; and discuss potential candidate biomarkers for improving the selection of patients who may respond to ICB.

Addressing Alcohol Use in Pregnancy.

Screening and brief counseling interventions are evidence-based approaches.

Preventing opioid overdose with peer-administered naloxone: findings from a rural state.

BACKGROUND: In response to the opioid epidemic, naloxone distribution programs aim to prevent overdose death by making naloxone available and training people to use it. Peers of individuals at risk of opioid overdose are well-positioned to administer naloxone and prevent overdose death. METHODS: We conducted key informant interviews with 18 individuals with past or current opioid and heroin drug use who had administered naloxone to a peer during an overdose emergency. Interviews explored individuals' experiences with administration and their recommendations for program and policy improvement. Data were systematically coded and analyzed for themes. RESULTS: Participants sought naloxone rescue kits because they perceived high risk of overdose. They described high satisfaction with training and felt prepared to administer naloxone during overdose incidents. Overwhelmingly, participants perceived naloxone to be effective and emphasized the need to make it widely available. Findings suggest that engagement in overdose prevention strategies other than naloxone differs by gender, with females more likely than males to use multiple different strategies. Participants described that overdose experiences do not have a lasting impact on drug use behaviors. CONCLUSIONS: Findings support the feasibility of naloxone distribution to peer opioid and heroin users and provide recommendations for policy improvement, including effective and well-advertised Good Samaritan laws and links to treatment for opioid use disorder.

Clinical Pan-Cancer Assessment of Mismatch Repair Deficiency Using Tumor-Only, Targeted Next-Generation Sequencing.

PURPOSE: Given regulatory approval of immune checkpoint inhibitors in patients with mismatch repair-deficient (MMR-D) cancers agnostic to tumor type, it has become important to characterize occurrence of MMR-D and develop cost-effective screening approaches. Using a next-generation sequencing (NGS) panel (OncoPanel), we developed an algorithm to identify MMR-D frequency in tumor samples and applied it in a clinical setting with pathologist review. METHODS: To predict MMR-D, we adapted methods described previously for use in NGS panels, which assess patterns of single base-pair insertion or deletion events occurring in homopolymer regions. Tumors assayed with OncoPanel between July 2013 and July 2018 were included. For tumors tested after June 2017, sequencing results were presented to pathologists in real time for clinical MMR determination, in the context of tumor mutation burden, other mutational signatures, and clinical data. RESULTS: Of 20,301 tumors sequenced, 2.7% (553) were retrospectively classified as MMR-D by the algorithm. Of 4,404 samples with pathologist sign-out of MMR status, the algorithm classified 147 (3.3%) as MMR-D: in 116 cases, MMR-D was confirmed by a pathologist, five cases were overruled by the pathologist, and 26 were assessed as indeterminate. Overall, the highest frequencies of OncoPanel-inferred MMR-D were in endometrial (21%; 152/723), colorectal (9.7%; 169/1,744), and small bowel (9.3%; 9/97) cancers. When algorithm predictions were compared with historical MMR immunohistochemistry or polymerase chain reaction results in a set of 325 tumors sequenced before initiation of pathologist assessment, the overall sensitivity and specificity of the algorithm were 91.1% and 98.2%, respectively. CONCLUSION: We show that targeted, tumor-only NGS can be leveraged to determine MMR signatures across tumor types, suggesting that broader biomarker screening approaches may have clinical value.

Epithelial to mesenchymal plasticity and differential response to therapies in pancreatic ductal adenocarcinoma.

Transcriptional profiling has defined pancreatic ductal adenocarcinoma (PDAC) into distinct subtypes with the majority being classical epithelial (E) or quasi-mesenchymal (QM). Despite clear differences in clinical behavior, growing evidence indicates these subtypes exist on a continuum with features of both subtypes present and suggestive of interconverting cell states. Here, we investigated the impact of different therapies being evaluated in PDAC on the phenotypic spectrum of the E/QM state. We demonstrate using RNA-sequencing and RNA-in situ hybridization (RNA-ISH) that FOLFIRINOX combination chemotherapy induces a common shift of both E and QM PDAC toward a more QM state in cell lines and patient tumors. In contrast, Vitamin D, another drug under clinical investigation in PDAC, induces distinct transcriptional responses in each PDAC subtype, with augmentation of the baseline E and QM state. Importantly, this translates to functional changes that increase metastatic propensity in QM PDAC, but decrease dissemination in E PDAC in vivo models. These data exemplify the importance of both the initial E/QM subtype and the plasticity of E/QM states in PDAC in influencing response to therapy, which highlights their relevance in guiding clinical trials.

CE: Original Research: Exploring Clinicians' Perceptions About Sustaining an Evidence-Based Fall Prevention Program.

: Purpose: This study aimed to address the knowledge gap between implementing and sustaining evidence-based fall prevention practices for hospitalized patients by exploring perspectives of the interprofessional health care team. DESIGN: A qualitative design was used to capture insights from clinicians across disciplines in a large midwestern academic medical center. METHODS: Four homogenous semistructured focus groups and three individual interviews involving a total of 20 clinicians were conducted between October 2013 and March 2014. Audio-recorded data were transcribed and analyzed using inductive qualitative analysis. FINDINGS: Two primary themes emerged from participants regarding the sustainability of an evidence-based fall prevention program: communication patterns within the interprofessional health care team and influences of hospital organizational practices and elements. Several subthemes also emerged. Participants gave nursing staff primary responsibility for fall risk assessment and prevention. CONCLUSIONS: Individual professional perceptions and practices, as well as organizational characteristics, affect the sustainability of evidence-based fall prevention practices. While all team members recognized patient falls as a significant quality and safety issue, most believed that direct care nurses hold primary responsibility for leading fall prevention efforts. The data support the importance of effective interprofessional team communication and organizational practices in sustaining an evidence-based fall prevention program across inpatient units. Furthermore, the data call into question the wisdom in labeling quality indicators as "nursing sensitive"; the evidence indicates that a team approach is best.

Management of Plantar KeratodermasLessons from Pachyonychia Congenita.

Plantar keratodermas can arise due to a variety of genetically inherited mutations. The need to distinguish between different plantar keratoderma disorders is becoming increasingly apparent because there is evidence that they do not respond identically to treatment. Diagnosis can be aided by observation of other clinical manifestations, such as palmar keratoderma, more widespread hyperkeratosis of the epidermis, hair and nail dystrophies, or erythroderma. However, there are frequent cases of plantar keratoderma that occur in isolation. This review focuses on the rare autosomal dominant keratin disorder pachyonychia congenita, which presents with particularly painful plantar keratoderma for which there is no specific treatment. Typically, patients regularly trim/pare/file/grind their calluses and file/grind/clip their nails. Topical agents, including keratolytics (eg, salicylic acid, urea) and moisturizers, can provide limited benefit by softening the skin. For some patients, retinoids help to thin calluses but may lead to increased pain. This finding has stimulated a drive for alternative treatment options, from gene therapy to alternative nongenetic methods that focus on novel findings regarding the pathogenesis of pachyonychia congenita and the function of the underlying genes.

Exercise after Stroke: Patient Adherence and Beliefs after Discharge from Rehabilitation.

BACKGROUND: Most people complete post-stroke rehabilitation within the first 6 months after stroke even though benefits from exercise are believed to persist well beyond 6 months. Physical and Occupational therapists provide home exercise programs (HEP) to instruct patients on exercises to continue after discharge from rehabilitation. Unfortunately, there is little known about HEP adherence rates in adults with stroke. OBJECTIVES: The objectives of this project were to (1) determine the adherence rate with post-rehabilitation HEP and reasons for non-adherence, (2) assess for interactions between HEP adherence and self-report of depression and fatigue, and (3) determine patient beliefs about the benefit of exercise during stroke recovery. DESIGN: This was a cross-sectional, survey study. METHODS: A survey was developed and distributed during stroke support group meetings to determine adherence rates with post rehabilitation HEP, reasons for non-adherence, and patient beliefs about the benefit of exercise. RESULTS: Eighty-nine percent of participants reported receiving a HEP and 65.3% of those reported being adherent with at least part of the HEP. Several reasons for non-adherence were identified, including 'doing different exercises than the ones given by the physical therapist', as the most frequently given reason. Study participants identified positive roles of exercise in their recovery from stroke. CONCLUSION: Patient adherence with HEP after discharge from rehabilitation is less than ideal. Reasons for non-adherence are varied. Rehabilitation therapists need to be able to identify and help patients manage barriers to HEP adherence to promote management of residual deficits.

Diagnosis and treatment of HLH in adults.

Hemophagocytic lymphohistiocytosis (HLH) is a rare life-threatening syndrome of uncontrolled immune activation. It was initially recognized in children, where it occurs primarily as an inherited syndrome related to homozygous null mutations in immune response genes involved in cytotoxic T cell and NK cell function. A minority of pediatric patients develop "secondary" HLH as a consequence of infection or autoimmune disease. In the last 10-15 years, secondary HLH has been increasingly recognized in adults, where it is frequently associated with lymphoid malignancy, infection, or autoimmune disease. This relatively recently recognized diagnosis and the treatment of adult HLH have been largely shaped by observations in pediatric patients. In this brief summary, we focus on the features that distinguish pediatric from adult HLH and discuss the challenges of diagnosis and treatment of this devastating disease.

In vivo response of GsdmA3(Dfl)/+ mice to topically applied fish oil - effects on cellular markers and macrophages.

Psoriasis is an incurable autoimmune disease characterized by patches of abnormal red, itchy and scaly skin. This work examined the modulation of inflammation, hyperproliferation and immune cell markers following topical application of fish oil (FO) in comparison to the antipsoriatic agents, betamethasone dipropionate (BD) and salicylic acid (SA), to GsdmA3(Dfl)/+ mice, a hair loss mutant which also exhibits epidermal hyperproliferation akin to psoriasis. The mice were dosed with 100 mg of the test formulation and after 10 days, the mice were sacrificed, skin sections excised and subjected to immunohistochemical determination of COX-2, K17 and MAC-1; and immunofluorescence of Ki-67. Unchanged expression of the proinflammatory enzyme COX-2 was observed in all treatments, suggesting the noninvolvement of COX-2 in the aetiology of cutaneous aberration seen in GsdmA3(Dfl)/+ mice. Intense staining of K17 and MAC-1 in the FO-treated group mirrored the epidermal thickening seen observed in live mice by optical coherence tomography (OCT). The ratio of Ki-67-positive nuclei per 100 basal cells indicated that hyperproliferation of keratinocytes occurred in FO-treated mice and the opposite was true for BD-treated mice. There was a positive correlation (R (2) 0.995) between Ki-67 and the epidermal thickness data observed previously. In all immunochemical procedures, the combined BD, SA and FO formulation did not show any significant difference with the control group, reflecting observations seen previously. In conclusion, the epidermal changes observed following topical FO treatment on GsdmA3(Dfl)/+ mice involves an increase in cellular proliferation and macrophages, although COX-2 does not appear to play an important role.

Clinicopathologic Features of NSCLC Diagnosed During Pregnancy or the Peripartum Period in the Era of Molecular Genotyping.

INTRODUCTION: Cancer will be diagnosed in one in 1000 women during pregnancy. The outcomes of NSCLC diagnosed during pregnancy are dismal, with most patients dying within 1 year. Actionable mutations are more likely to be found among younger patients with NSCLC. However, most previous reports of NSCLC diagnosed during pregnancy did not include molecular genotyping. METHODS: We performed a retrospective analysis of patients seen at our institution between 2009 and 2015 to identify women in whom NSCLC was diagnosed during pregnancy or the peripartum period and determined clinicopathologic features, including molecular genotype. RESULTS: We identified 2422 women with NSCLC, including 160 women of reproductive age. Among the women of reproductive age, eight cases of NSCLC diagnosed during pregnancy or the peripartum period were identified; all were diagnosed in minimal or never-smokers with metastatic adenocarcinoma. Six of these patients were found to have anaplastic lymphoma kinase gene (ALK) rearrangements, whereas the remaining two were EGFR mutation positive. We observed a borderline significant association between a diagnosis of NSCLC during pregnancy or the peripartum period and ALK positivity (p = 0.053). All eight women in whom NSCLC was diagnosed during pregnancy or the peripartum period received treatment with genotype-directed therapies after delivery. The median overall survival has not been reached at a median follow-up of 30 months. CONCLUSIONS: Although a diagnosis of NSCLC during pregnancy or the peripartum period is rare, diagnostic evaluation should not be delayed in pregnant women presenting with symptoms worrisome for lung cancer. Evaluation should include testing for targetable molecular alterations.

Evidence and conjecture about mechanisms of cutaneous disease in photodermatology.

Photosensitivity disorders are caused by a variety of mechanisms. Three common themes are as follows: excess chromophore allowing visible light energy to cause photodynamic damage, reduced DNA repair capacity to UV-induced DNA damage, and enhanced sensitivity to light-induced allergens mediated immunologically. Although the cause of each condition may be known, the precise pathogenesis underlying the photosensitivity has taken longer to understand. By focussing on three clinical disorders under each of these themes, we have explored the following: why erythropoietic protoporphyria differs so markedly from the other cutaneous porphyrias; how a DNA repair defect was eventually revealed to be the underlying cause of the vitamin B3 deficiency disorder of pellagra; an immunological explanation for the over reactivity to photoallergens in chronic actinic dermatitis.

Intense pulsed light may improve inflammatory acne through TNF-α down-regulation.

BACKGROUND: Despite many studies on the action of yellow light in acne, its efficacy and mechanisms of action are still unclear. OBJECTIVES: To determine if IPL can cause a clinical improvement in acne and whether it modifies TLR2 and TNFα expression. METHODS: Twenty-one patients with mild to moderate acne involving their backs received 530 nm IPL treatments once every 2 weeks. Assessments at baseline and after the fourth treatment included lesion counts, Leeds grading and SER. Biopsies from the treatment area were taken at three time points. TLR2 expression was determined using immunohistochemistry, and TaqMan Low Density Arrays were used to measure TNFα, IL-8 and IL-10. RESULTS: Inflamed lesion counts fell significantly by 28.0% (p = 0.002) but not the Leeds score, SER or non-inflamed lesions. A reduction in TNFα expression of 17.6% (p = 0.031) weakly correlated with the change in lesion counts. TLR2 expression fell by 2.6% (p < 0.001) but did not correlate with lesion counts. Neither IL-10 nor IL-8 expression was significantly altered. CONCLUSIONS: 530 nm IPL significantly reduces inflammatory lesions, where its efficacy will need optimising to make it a viable treatment option. Its mechanism seems to include a novel anti-TNFα effect, independent of IL-10 up-regulation.