Fluorescence anisotropic probe for sensing cardiac troponin-I antigen through target-specific antibody-conjugated gold nanoclusters.

Fluorescence anisotropy (FA) is a versatile and efficient platform for developing biosensors that rely on the rate of rotations of fluorescence molecular entities in biochemical systems. However, by virtue of its intricate complexity, FA is a neglected and less explored area for developing biosensors. Herein, we experimented with the possibility of developing a fluorescence anisotropic probe to detect cardiac troponin I (cTnI), the gold standard biomarker for acute myocardial infarction, via target-specific monoclonal antibody-conjugated gold nanoclusters. The successful detection of cTnI antigen in clinically relevant concentration with a low detection limit of 0.91 ng mL-1 was achieved. The specific molecular interaction between the cTnI antigen and its monoclonal antibody tagged at the surface of gold nanoclusters has restricted the free rotation of gold nanoclusters and increased the FA value. This incremental increase in FA can be correlated to the concentration of cTnI antigen in the sample, thereby achieving the quantitative linear detection of cTnI.

Non-enzymatic Detection of Cardiac Troponin-I with Graphene Oxide quenched Fluorescent Iron Nanoclusters (FeNCs).

Cardiac troponin I (cTnI) is the most resorted biomarker for the detection of cardiovascular disease (CVD). The means of rapid quantification of cTnI levels in the blood can substantially minimize the risk of acute myocardial infarction and heart failure. A sensor for the non-enzymatic evaluation of cardiac troponin-I has been developed using fluorescent iron nanoclusters via a one-pot synthesis employing (BSA) as the template and reducing agent, and hydrogen peroxide as the additive. The fluorescence of Iron Nanocluster is quenched with graphene oxide (GO) via fluorescence resonance energy transfer (FRET) between conjugate iron nanoclusters and graphene oxide. The sensor shows a low detection limit of 0.013 ng/mL. The benefits of utilizing a non-enzymatic probe for detecting cardiac troponin I is that it avoids the need for enzymes and hence is economical, stable, and less impacted by environmental conditions such as temperature and pH. Non-enzymatic probes are more useful for clinical use since they are more stable and have a longer shelf life. The developed non-enzymatic probes are also highly selective and sensitive to the target analyte, making them suitable for the direct detection of cardiac troponin I in actual biological samples.

Luminescence "Turn-On" Sensing of Brain Natriuretic Peptide (BNP) - Dilated Cardiomyopathy Biomarker Based on the MoS2 Nanosheet Quenched Terbium Citrate Complex.

Dilated cardiomyopathy (DCM), known as myocardial metabolic dysfunction, is recognized as a clinical condition characterized by left ventricular dilation or improper contraction of cardiac muscles in the absence of coronary atherosclerosis and hypertension. It is an independent risk factor for cardiac function caused by a hyperglycemic condition in diabetic patients leading to heart failure (HF), which renders the early diagnosis of DCM highly challenging. Hence, detection of early diagnostic biomarkers in blood serum to identify DCM conditions is quite requisite. Brain natriuretic peptide (BNP) is a well-recognized biomarker for heart failure and reported as an early diagnostic biomarker for DCM. In this work, we developed a terbium citrate based MoS2 nanosheet (NS) coupled immunoprobe for the sensitive detection of BNP. The antibody conjugated Tb-citrate complex exhibits green fluorescence, which is quenched by the introduction of MoS2 NS. On subsequent addition of antigen BNP, the fluorescence is enhanced because of specific antigen-antibody interaction. The probe is selective and sensitive toward BNP in a linear range from 30.76 to 849.85 pg/mL with a low LOD of 3.87 pg/mL. The probe is validated in spiked human serum samples with good recovery percentage.

Integrative genomic and transcriptomic profiling of pulmonary sarcomatoid carcinoma identifies molecular subtypes associated with distinct immune features and clinical outcomes.

Background: Pulmonary sarcomatoid carcinoma (PSC) is a rare and aggressive subtype of non-small cell lung cancer (NSCLC), characterized by the presence of epithelial and sarcoma-like components. The molecular and immune landscape of PSC has not been well defined. Methods: Multiomics profiling of 21 pairs of PSCs with matched normal lung tissues was performed through targeted high-depth DNA panel, whole-exome, and RNA sequencing. We describe molecular and immune features that define subgroups of PSC with disparate genomic and immunogenic features as well as distinct clinical outcomes. Results: In total, 27 canonical cancer gene mutations were identified, with TP53 the most frequently mutated gene, followed by KRAS. Interestingly, most TP53 and KRAS mutations were earlier genomic events mapped to the trunks of the tumors, suggesting branching evolution in most PSC tumors. We identified two distinct molecular subtypes of PSC, driven primarily by immune infiltration and signaling. The Immune High (IM-H) subtype was associated with superior survival, highlighting the impact of immune infiltration on the biological and clinical features of localized PSCs. Conclusions: We provided detailed insight into the mutational landscape of PSC and identified two molecular subtypes associated with prognosis. IM-H tumors were associated with favorable recurrence-free survival and overall survival, highlighting the importance of tumor immune infiltration in the biological and clinical features of PSCs.

Terbium Phenanthroline Complex as a Luminescent Probe for the Detection of Anthrax Biomarker: Dipicolinic acid.

Dipicolinic acid (DPA) is a prominent biomarker for Anthrax disease. Bacillus anthracis bacterial endospores is composed of DPA as the significant component, which on over inhalation can cause severe health issues. Such contagious and life-threatening pathogens can be employed as bioweapons or biothreat agents for spreading bioterrorism which is a major risk for national security and public health concerns. Hence, effective detection or a surveillance system is essential for preventing the growth of bioterrorism events. Herein, we have developed a Terbium - 1,10 Phenanthroline (Tb-Phen) based lanthanide luminescence complex with bright green fluorescence. On addition of DPA, the green fluorescence is turn-off at a linear range from 0.6 to 4.762 mM. In this effect, 5D4- 7F5 transition caused by 1,10-phenanthroline to Tb3+ at 544 nm is restricted due to energy transfer quenching and Inner Filter Effect (IFE). The developed probe shows good sensitivity towards the detection of DPA with other coexisting biomolecules and ions with a low Limit of Detection (LOD) of 5.029 µM. The practical feasibility was evaluated in paper strip assay and extended in real samples such as human serum and tap water with satisfactory recovery percentage. Thereby, probe finds promising application in sensing of anthrax spore biomarker (DPA) and biothreat agents.

Efficient nanostructured Cs2CuBr2Cl2 perovskite as a fluorescent sensor for the selective "Switch Off" detection of nitrobenzene.

Lead halide nanostructured perovskites are well known for their excellent photoluminescence and optoelectronic properties. However, lead toxicity and instability in moisture impedes its suitability for material use. Here we synthesized a highly efficient, lead free, economical, stable Cs2CuBr2Cl2 perovskite nanocrystals (PNCs) via Ligand Assisted Re-Precipitation (LARP) method which is less explored. The sensing application of the synthesized PNCs towards nitro explosives and other small organic compounds were studied. The probe exhibited high selectivity towards nitrobenzene with a lowest detection limit of 57.64 nM. The fluorescent emission intensity was drastically quenched upon the addition of 32 µM nitrobenzene. A Stern-Volmer plot was utilized for the quantification of fluorescence quenching. Further to investigate the quenching mechanism, time correlated single photon counting spectroscopy and other photoluminescence studies were performed pointing out the possibility of fluorescence resonance energy transfer. The work has been further extended to test the capability of the probe to detect nitrobenzene in real water samples and a good recovery percentage ranging from 93-98 % was obtained. Further, a paper strip assay was designed which successfully detected nitrobenzene and can be clearly noticed even with our naked eye making the probe an excellent sensor for nitrobenzene detection.

Mo(IV) Ion-Modulated BSA-Protected Gold Nanocluster Probe for Fluorescence Turn-On Detection of Trimethylamine N-Oxide (TMAO).

Trimethylamine N-oxide (TMAO), a molecule produced by the microbiota, has been associated with human health and illness. Its early discovery in body fluids may affect our understanding of the pathophysiology and treatment of many illnesses. Therefore, our knowledge of the pathophysiology and diagnostics of disorders associated with TMAO might be enhanced by the creation of dependable and fast methods for TMAO detection. Therefore, we developed a fluorescent probe for detecting TMAO utilizing an on-off-on strategy. Bovine serum albumin (BSA)@AuNCs luminescence is effectively quenched by Mo4+ because BSA@AuNCs and Mo4+ have a strong binding relationship. Mo4+ ions can substantially decrease the emission intensity of gold nanoclusters by establishing a BSA@AuNCs-Mo system. Then, the luminescence of BSA@AuNCs was restored due to the interaction between Mo4+ and TMAO. A significant linear relationship was seen between the emission intensity and TMAO concentration within the 0-201 µM range, with a detection limit of 1.532 µM. Additionally, the method can measure TMAO in blood and urine samples.

MnO2 nanosheet quenched thulium doped photon-up conversion luminescent immunoprobe for the 'turn-on' detection of cardiac troponin T.

A "turn-on" photon up conversion nano couple based on NaYF4: Yb, Tm UCNPs quenched with MnO2 nanosheet was developed for the rapid and selective detection of cTnT. Herein, MnO2 nanosheet hold on the surface of Antibody cTnT (Ab-cTnT) conjugated blue emitting up conversion nanoprobe (λem at 475 nm), which leads to quenching of fluorescence due to energy transfer from photon up conversion nanoparticles to MnO2 nanosheets. On introducing cTnT antigen to the system, the energy transfer process is hindered due to strong antigen -antibody interface on the surface. This in turn, influences the nano-couples positions and effectively separates up conversion nanoprobe from MnO2 nanosheets surface resulting in restriction to energy transfer process enabling fluorescence recovery. The developed probe shows a linear response towards cTnT in the range of 0.16-2.77 ng/mL with a Limit of Detection (LoD) of 0.025 ng/mL. The practical feasibility of the nanoprobe is performed with possible coexisting biomolecules. Biological study in human blood serum samples exhibited sufficient recovery percentage in the range of 92-103 % is obtained.

Highly sensitive lanthanide complex as a probe for l-kynurenine: A cancer biomarker.

A lanthanide complex based on europium (Eu) and chelidamic acid was synthesized (Eu-CHE) and characterized. The complex Eu-CHE exhibited intense luminescence at 615 nm under excitation at 300 nm and was further investigated for highly sensitive turn-off detection of l-kynurenine (l-kyn), a cancer biomarker. The probe detected l-kyn linearly from 6 nM to 0.2 µM with a limit of detection and limit of quantification of 1.37 and 4.57 nM, respectively. The probe was investigated for selectivity towards l-kyn among co-existing amino acids and further extended for detecting l-kyn from human serum and urine samples. A low-cost paper strip-based sensing platform was also developed for the visual detection of l-kyn.

Antibody-functionalized gold nanoclusters/gold nanoparticle platform for the fluorescence turn-on detection of cardiac troponin I.

A selective fluorescence turn-on immunosensor for the specific detection of cardiac troponin I (cTnI), the potent biomarker for myocardial infarction diagnosis, was developed with a nano couple comprised of protein-stabilized gold nanocluster and gold nanoparticle. The red fluorescence of cTnI-specific antibody tagged bovine serum albumin stabilized gold nanoclusters was quenched with gold nanoparticles (AuNP) via the intensive interaction between amine and hydroxyl functionalities of BSA and AuNP. Through this, the adsorption of gold nanoclusters at the surface of AuNP, resulting in a core-satellite assembly, was assumed to quench the fluorescence emission. While in the presence of cTnI antigen, this gets disturbed due to the formation of immunocomplex between cTnI antigen and antibody, which restricts the close interaction between gold clusters and nanoparticles, thereby restoring quenched fluorescence. The enhancement in fluorescence signal is directly related to the concentration of cTnI, and this facilitates the selective detection of cTnI in the linear concentration range 0.7 to 10 ng/mL without any interference from other potentially interfering co-existing biomolecules. An appreciable limit of detection of 0.51 ng/mL and a limit of quantification of 0.917 ng/mL for cTnI is comparable to that of the previous report.

Fluorescent Enzymatic Sensor Based Glucose Oxidase Modified Bovine Serum Albumin-Gold Nanoclusters for Detection of Glucose.

An enzymatic fluorescent probe is developed for the selective detection of glucose. In this work, a Bovine Serum Albumin stabilized gold nanocluster (BSA-AuNCs) was synthesized by microwave assisted method, and it is modified with glucose oxidase, thereby a fluorescent enzymatic sensor (BSA-AuNCs@GoX) was designed for the sensitive detection of glucose with a limit of detection of 0.03 mM. The red fluorescence exhibited by the probe is quenched by the production of H2O2 on addition of glucose via. a static quenching mechanism from UV visible absorption and Fluorescence lifetime results. The developed probe exhibits good selectivity and sensitivity with other coexisting molecular species such as glycine, creatinine, methionine, histidine, uric acid, albumin, and ions such as sodium, potassium, calcium, magnesium, zinc etc. that appear in the body fluid. The practical applicability was studied in paper strip and extended its reproducibility in biological matrixes such as human serum and urine and found a good recovery percentage of 94-101 %. By this way, we have fabricated an effective fluorescent enzymatic "turn-off" sensing probe for the detection of glucose.

L-Methionine and D-Methionine Capped Fluorescent Silicon Quantum Dots Based Probes for Turn on Sensing of Glutathione - A Comparative Study.

Oral Squamous Cell Carcinoma (OSCC), a prevalent type of oral cancer originates in squamous cells that develop due to tobacco use, excess alcohol consumption, human papillomavirus infection, chronic irritation and weakened immune system. When detected early, survival rates of OSCC can be increased to more than 85%. Hence its early detection is crucial for appropriate management. Oxidative stress has a vital role in pathogenesis of various cancers including OSCC. Early detection of OSCC can be done by exploring serum Glutathione (GSH); an oxidative stress biomarker. Herein, we have developed two Silicon quantum dots (SiQDs); (L-methionine capped Silicon quantum dots (LSiQDs) and D-methionine capped Silicon quantum dots (DSiQDs)) and their fluorescence was quenched with Cu2+. The obtained Cu@LSiQDs and Cu@DSiQDs were then explored and compared for sensing GSH. Both the SiQDs were checked for selectivity and interference studies using coexisting biomolecules extended for sensing GSH from real samples. Moreover, a paper strip assay was also developed and compared.

NaYF4:Yb/Ho upconversion nanoprobe incorporated gold nanoparticle (AuNP) based FRET immunosensor for the "turn-on" detection of cardiac troponin I.

Cardiac troponin I (cTnI) is a significant biomarker for acute heart attack. Hence, fast, economical, easy and real time monitoring of cardiac troponin I (cTnI) is of great importance in diagnosis and prognosis of heart failure in the healthcare domain. In this work, an immunoassay based on NaYF4:Yb/Ho based photon-upconversion nanoparticle (UCNP) with narrow emission peaks at 540 nm and 655 nm respectively, is synthesized. Then, it is encapsulated with amino functionalized silica using 3-aminopropyltriethoxysilane (APTES) to form APTES@SiO2-NaYF4:Yb/Ho UCNPs. When AuNPs is added to this system, the fluorescence is quenched by the electrostatic interaction with APTES@SiO2-NaYF4:Yb/Ho UCNPs, thereby exhibiting a FRET-based biosensor. When the cTnI antigen is introduced into the developed probe, an antibody-antigen complex is formed on the surface of the UCNPs resulting in fluorescence recovery. The developed sensor shows a linear response towards cTnI in the range from 0.1693 ng mL-1 to 1.9 ng mL-1 with a low limit of detection (LOD) of 5.5 × 10-2 ng mL-1. The probe exhibits adequate selectivity and sensitivity when compared with coexisting cardiac biomarkers, biomolecules and in real human serum samples.

Efficacy and clinicogenomic correlates of response to immune checkpoint inhibitors alone or with chemotherapy in non-small cell lung cancer.

The role of combination chemotherapy with immune checkpoint inhibitors (ICI) (ICI-chemo) over ICI monotherapy (ICI-mono) in non-small cell lung cancer (NSCLC) remains underexplored. In this retrospective study of 1133 NSCLC patients, treatment with ICI-mono vs ICI-chemo associate with higher rates of early progression, but similar long-term progression-free and overall survival. Sequential vs concurrent ICI and chemotherapy have similar long-term survival, suggesting no synergism from combination therapy. Integrative modeling identified PD-L1, disease burden (Stage IVb; liver metastases), and STK11 and JAK2 alterations as features associate with a higher likelihood of early progression on ICI-mono. CDKN2A alterations associate with worse long-term outcomes in ICI-chemo patients. These results are validated in independent external (n = 89) and internal (n = 393) cohorts. This real-world study suggests that ICI-chemo may protect against early progression but does not influence overall survival, and nominates features that identify those patients at risk for early progression who may maximally benefit from ICI-chemo.

Folic acid incorporated nitrogen-doped carbon dots as a turn-on fluorescence probe for homocysteine detection.

This study describes the development of a low-cost fluorescence assay for detecting homocysteine (Hcy) without the interference of cysteine and glutathione using carbon quantum dots. Herein nitrogen-doped carbon quantum dots (NCDs) were synthesized from citric acid as the carbon source and urea as the dopant using a one-pot microwave-assisted method. The obtained NCDs were incorporated with folic acid (FA) by the direct ex situ addition method and were used as a fluorescence probe to detect Hcy. The probe exhibited a fluorescence turn-on response with increased Hcy concentration up to 50 µM with a limit of detection of 2.276 µM. The point of care detection of Hcy using the probe was also tested with a paper-based assay strip.

Limited Benefit from the Addition of Immunotherapy to Chemotherapy in TKI-Refractory EGFR-Mutant Lung Adenocarcinoma.

BACKGROUND: The benefit of chemotherapy combined with immunotherapy in EGFR-mutant lung adenocarcinoma (LUAD) patients whose tumor developed resistance to EGFR tyrosine kinase inhibitors (TKIs) is not thoroughly investigated. The goal of this retrospective cohort study is to assess the clinical efficiency of immunotherapy alone or in combination with chemotherapy in a real-world setting. METHODS: This retrospective cohort study enrolled LUAD patients with EGFR sensitive mutations whose tumor had acquired resistance to EGFR TKIs and received systemic treatment with chemotherapy (chemo; n = 84), chemotherapy combined with immunotherapy (chemoIO; n = 30), chemotherapy plus bevacizumab with or without IO (withBev; n = 42), and IO monotherapy (IO-mono; n = 22). Clinical progression-free survival (PFS) and overall survival (OS) were evaluated. Associations of clinical characteristics with outcomes were assessed using univariable and multi-covariate Cox Proportional Hazards regression models. RESULTS: A total of 178 patients (median age = 63.3; 57.9% females) with a median follow-up time of 42.0 (Interquartile range: 22.9-67.8) months were enrolled. There was no significant difference in PFS between chemoIO vs. chemo groups (5.3 vs. 4.8 months, p = 0.8). Compared to the chemo group, patients who received withBev therapy trended towards better PFS (6.1 months vs. 4.8; p = 0.3; HR 0.79; 95% CI: 0.52-1.20), while patients treated with IO-mono had inferior PFS (2.2 months; p = 0.001; HR 2.22; 95% CI: 1.37-3.59). Furthermore, PD-L1 level was not associated with PFS benefit in the chemoIO group. Patients with EGFR-mutant LUAD with high PD-L1 (≥50%) had shorter PFS (5.8 months) than non-EGFR/ALK LUAD patients who received chemoIO (12.8 months, p = 0.002; HR 0.22; 95% CI: 0.08-0.56) as first-line treatment. Chemotherapy-based therapy rendered similar benefit to patients with either EGFR exon19 deletion vs. L858R in the LUAD. CONCLUSIONS: This retrospective analysis revealed that immunotherapy provided limited additional benefit to chemotherapy in TKI-refractory EGFR-mutant LUAD. Chemotherapy alone or combined with bevacizumab remain good choices for patients with actionable EGFR mutations.

The histologic phenotype of lung cancers is associated with transcriptomic features rather than genomic characteristics.

Histology plays an essential role in therapeutic decision-making for lung cancer patients. However, the molecular determinants of lung cancer histology are largely unknown. We conduct whole-exome sequencing and microarray profiling on 19 micro-dissected tumor regions of different histologic subtypes from 9 patients with lung cancers of mixed histology. A median of 68.9% of point mutations and 83% of copy number aberrations are shared between different histologic components within the same tumors. Furthermore, different histologic components within the tumors demonstrate similar subclonal architecture. On the other hand, transcriptomic profiling reveals shared pathways between the same histologic subtypes from different patients, which is supported by the analyses of the transcriptomic data from 141 cell lines and 343 lung cancers of different histologic subtypes. These data derived from mixed histologic subtypes in the setting of identical genetic background and exposure history support that the histologic fate of lung cancer cells is associated with transcriptomic features rather than the genomic profiles in most tumors.

Hyaluronic acid coated Pluronic F127/Pluronic P123 mixed micelle for targeted delivery of Paclitaxel and Curcumin.

The hydrophobicity of most of the anticancer drugs offers a great challenge in selecting a system for their effective transport. Here comes the importance of micelles that offers a hydrophobic core for incorporating these drugs. In this study, Hyaluronic Acid coated Pluronic mixed micelle loaded with Paclitaxel and Curcumin was designed and evaluated its anticancer activity in MCF-7 cells. Pluronic F127 (PF127) and Pluronic P123 (PP123) were taken for preparing the mixed micelles. The targeting ligand folic acid (FA) was conjugated to one end of PP123 forming FA-PP. The end hydroxyl groups of PF127 were oxidized to aldehyde groups resulted in PF-CHO. Mixed micelles were prepared from PF-CHO and FA-PP and the end aldehyde groups were used for coating the micelles with hyaluronic acid. The material was characterized using FTIR, H1NMR, DLS, FE-SEM and TEM. The coated micelles showed spherical shape with drug loading efficiency of 50.15 and 65.05% for Paclitaxel and Curcumin, respectively. In vitro drug release was studied at pH 5.5 and 7.4. Dual drug-loaded material showed higher in-vitro anticancer activity than free Paclitaxel and Curcumin. The results suggested that synthesized mixed micelle with dual drugs showed great potential for targeted delivery to MCF-7 cells.

Structure-based classification predicts drug response in EGFR-mutant NSCLC.

Epidermal growth factor receptor (EGFR) mutations typically occur in exons 18-21 and are established driver mutations in non-small cell lung cancer (NSCLC)1-3. Targeted therapies are approved for patients with 'classical' mutations and a small number of other mutations4-6. However, effective therapies have not been identified for additional EGFR mutations. Furthermore, the frequency and effects of atypical EGFR mutations on drug sensitivity are unknown1,3,7-10. Here we characterize the mutational landscape in 16,715 patients with EGFR-mutant NSCLC, and establish the structure-function relationship of EGFR mutations on drug sensitivity. We found that EGFR mutations can be separated into four distinct subgroups on the basis of sensitivity and structural changes that retrospectively predict patient outcomes following treatment with EGFR inhibitors better than traditional exon-based groups. Together, these data delineate a structure-based approach for defining functional groups of EGFR mutations that can effectively guide treatment and clinical trial choices for patients with EGFR-mutant NSCLC and suggest that a structure-function-based approach may improve the prediction of drug sensitivity to targeted therapies in oncogenes with diverse mutations.

Subjective functional outcomes in oropharyngeal cancer treated with induction chemotherapy using the MD Anderson Symptom Inventory (MDASI).

OBJECTIVES: Evaluate the use of induction chemotherapy (IC) in oropharyngeal cancer (OPC) and its impact on subjective functional outcomes using a validated MD Anderson Symptom Inventory-Head and Neck (MDASI-HN) survey tool. METHODS: A single institution retrospective review of OPC patients who received IC, including reasons given for using IC, regimens employed, responses, and patient-reported outcomes (PRO). The latter included pain, distress, dysphagia, xerostomia, and feeding tube placement and dependency. PRO's were assessed using the validated MD Anderson Symptom Inventory-Head and Neck (MDASI-HN) conducted at baseline, during treatment, and at six-month follow up. RESULTS: One hundred and twenty-five patients were evaluable. They were more likely to have large primary and/or bulky or low neck nodal disease as a reason for IC. A taxane-containing regimen was most common. Primary tumor response was seen in 83.2% and the nodal response in 81.6%. Pain and xerostomia improved with IC, dysphagia was not adversely affected with IC. These symptoms all increased with consolidation chemoradiotherapy (CRT) but returned to baseline by 6 months post treatment. Feeding tube placement did not increase with IC but did with CRT, most patients were no longer feeding tube dependent at 6 months. CONCLUSION: This retrospective review of subjective functional outcomes, especially swallowing and feeding tube dependency, using the MDASI survey tool in 125 oropharyngeal cancer patients with large primary tumors and/or bulky adenopathy treated predominantly with platinum-taxane based induction chemotherapy showed that such outcomes were not adversely impacted. While not standard, such approach may be beneficial in such patients. LEVEL OF EVIDENCE: 2.