Gastrointestinal Stromal Tumour of the Appendix: A Very Rare Entity.

A 74-year-old man who presented with upper abdominal pain was found to have an incidental appendiceal mass on cross-sectional imaging. He underwent a laparoscopic appendicectomy with histopathological examination confirming a completely resected appendiceal gastrointestinal stromal tumour (GIST). Appendiceal GISTs are rare. Therefore, there is limited evidence to guide risk stratification and management with extrapolation of prognosis from data on GISTs at other sites. This paper highlights the rarity of these tumours and presents another case which correlates well with the existing but limited literature. There is a need to maintain a registry of this rare disease entity with the maintenance of longer-term follow-up data.

A Qualitative Intervention Evaluation of Neonatal Virtual Family-Centered Rounds.

OBJECTIVE: To conduct an implementation evaluation of the virtual family-centered rounds (FCR) intervention by exploring the perceptions and experiences of parents and care team providers. METHODS: We conducted a qualitative descriptive study using a thematic analysis of unobtrusive observations of rounding encounters and semi-structured interviews with the parents of discharged infants and members of the neonatal care team. Eligible participants had used virtual FCR at least once. Five research team members independently performed focused coding and memo writing of transcripts and observation fieldnotes. The team met weekly to compare and refine codes, update the interview guide, develop tentative categories, and discuss the theoretical direction. RESULTS: We conducted 406 minutes of unobtrusive observations and 21 interviews with parents, physicians, neonatal nurse practitioners, bedside nurses, dieticians, and pharmacists. Three themes and 13 subthemes emerged from the analysis: (1) virtual FCR improved perceived care delivery and clinical outcomes through increased opportunities for parent engagement, (2) the acceptance of virtual FCR by providers grew over time despite the persistent presence of technical challenges, and (3) the implementation of virtual FCR should be standardized and delivered by the care team to enhance usability, effectiveness, and sustainability. CONCLUSIONS: Virtual FCR is perceived by NICU parents and care team providers to be a valuable intervention that can enhance family centered care. The identified virtual FCR implementation strategies should be tested in further studies.

The Introduction of Magtrace® Lymphatic Tracer for Axillary Sentinel Node Biopsy for Breast Cancer in a Rural Scottish District General Hospital: Initial Experience, Perspectives, Outcomes and Learning Curves.

BACKGROUND: Magtrace is a supraparamagnetic iron lymphatic tracer that has had increasing use in sentinel node biopsy (SNB) for breast cancer and has theoretical logistical benefits in centres where nanocolloid use may be associated with such issues. We describe our initial experience with the introduction of Magtrace into our routine practice by dual localisation with nanocolloid, comparing performance, and concordance. MATERIALS AND METHODS: This was prospective study of the first patients undergoing axillary SNB using Magtrace in a single centre. These patients had dual localisation with nanocolloid and Magtrace. Subjective global assessments of Magtrace and nanocolloid performance as well as objective signal strength and anatomical concordance were compared across multiple timepoints in the operative journey. RESULTS: A total of 30 consecutive patients underwent SNB within the timeframe of this study. While there were no failed SNB, 8 issues were reported including 4 issues of perceived imperfect localisation on global assessment. No patient had a failed or abandoned SNB, and only 1 case had a potential challenge in subsequent management after histopathological examination of the retrieved nodes. The majority of these issues occurred in the first half of the study period. There was overall weak to moderate positive correlation between Magtrace and nanocolloid signals of the retrieved sentinel nodes (Spearman's ρ = 0.392, P = .043). CONCLUSION: This study suggests that introducing Magtrace was feasible and safe in the context of a rural breast cancer service. A possible strategy to ameliorate the learning curve associated with these procedures is the routine dual localisation in the initial phases of performing Magtrace localisation.

Investigation of the activity of a novel tropolone in osteosarcoma.

Osteosarcoma (OS) is a primary malignant bone tumor characterized by frequent metastasis, rapid disease progression, and a high rate of mortality. Treatment options for OS have remained largely unchanged for decades, consisting primarily of cytotoxic chemotherapy and surgery, thus necessitating the urgent need for novel therapies. Tropolones are naturally occurring seven-membered non-benzenoid aromatic compounds that possess antiproliferative effects in a wide array of cancer cell types. MO-OH-Nap is an α-substituted tropolone that has activity as an iron chelator. Here, we demonstrate that MO-OH-Nap activates all three arms of the unfolded protein response (UPR) pathway and induces apoptosis in a panel of human OS cell lines. Co-incubation with ferric chloride or ammonium ferrous sulfate completely prevents the induction of apoptotic and UPR markers in MO-OH-Nap-treated OS cells. MO-OH-Nap upregulates transferrin receptor 1 (TFR1) protein levels, as well as TFR1, divalent metal transporter 1 (DMT1), iron-regulatory proteins (IRP1, IRP2), ferroportin (FPN), and zinc transporter 14 (ZIP14) transcript levels, demonstrating the impact of MO-OH-Nap on iron-homeostasis pathways in OS cells. Furthermore, MO-OH-Nap treatment restricts the migration and invasion of OS cells in vitro. Lastly, metabolomic profiling of MO-OH-Nap-treated OS cells revealed distinct changes in purine and pyrimidine metabolism. Collectively, we demonstrate that MO-OH-Nap-induced cytotoxic effects in OS cells are dependent on the tropolone's ability to alter cellular iron availability and that this agent exploits key metabolic pathways. These studies support further evaluation of MO-OH-Nap as a novel treatment for OS.

BG2: Bayesian variable selection in generalized linear mixed models with nonlocal priors for non-Gaussian GWAS data.

BACKGROUND: Genome-wide association studies (GWASes) aim to identify single nucleotide polymorphisms (SNPs) associated with a given phenotype. A common approach for the analysis of GWAS is single marker analysis (SMA) based on linear mixed models (LMMs). However, LMM-based SMA usually yields a large number of false discoveries and cannot be directly applied to non-Gaussian phenotypes such as count data. RESULTS: We present a novel Bayesian method to find SNPs associated with non-Gaussian phenotypes. To that end, we use generalized linear mixed models (GLMMs) and, thus, call our method Bayesian GLMMs for GWAS (BG2). To deal with the high dimensionality of GWAS analysis, we propose novel nonlocal priors specifically tailored for GLMMs. In addition, we develop related fast approximate Bayesian computations. BG2 uses a two-step procedure: first, BG2 screens for candidate SNPs; second, BG2 performs model selection that considers all screened candidate SNPs as possible regressors. A simulation study shows favorable performance of BG2 when compared to GLMM-based SMA. We illustrate the usefulness and flexibility of BG2 with three case studies on cocaine dependence (binary data), alcohol consumption (count data), and number of root-like structures in a model plant (count data).

Cytologic atypia of benign inflammatory versus neoplastic cutaneous squamous lesions.

BACKGROUND: Cytologic atypia encompasses several features of abnormal cellular morphology. We sought to quantify these features in benign and premalignant/malignant squamous cell lesions to better characterize criteria for malignancy. METHODS: We conducted a rater-blinded observational study in which histopathology slides were evaluated under light microscopy, and the presence and relative quantity of 24 distinct cytological features were recorded, along with respective diagnoses. Each slide was evaluated, and the ratings were recorded and analyzed. RESULTS: The most helpful findings, whose presence in high numbers indicates an increased likelihood that the tissue sample is premalignant/malignant, were: (1) pleomorphic parakeratosis; (2) pleomorphic nuclei in the epithelium; (3) irregular nuclei; (4) thick refractile nuclear envelope; (5) presence of nuclear hyperchromasia (dark gray); (6) peripheral nucleoli; and (7) nucleolar stems. Higher values of round or oval nuclear shape and vesicular nuclei increase the likelihood that the tissue sample is benign. CONCLUSIONS: Certain nuclear features have a higher association with premalignancy/malignancy and may guide histologic evaluation of a given lesion. These findings can be used in combination with architectural features and clinical history to add to a complete diagnostic picture.

BGWAS: Bayesian variable selection in linear mixed models with nonlocal priors for genome-wide association studies.

BACKGROUND: Genome-wide association studies (GWAS) seek to identify single nucleotide polymorphisms (SNPs) that cause observed phenotypes. However, with highly correlated SNPs, correlated observations, and the number of SNPs being two orders of magnitude larger than the number of observations, GWAS procedures often suffer from high false positive rates. RESULTS: We propose BGWAS, a novel Bayesian variable selection method based on nonlocal priors for linear mixed models specifically tailored for genome-wide association studies. Our proposed method BGWAS uses a novel nonlocal prior for linear mixed models (LMMs). BGWAS has two steps: screening and model selection. The screening step scans through all the SNPs fitting one LMM for each SNP and then uses Bayesian false discovery control to select a set of candidate SNPs. After that, a model selection step searches through the space of LMMs that may have any number of SNPs from the candidate set. A simulation study shows that, when compared to popular GWAS procedures, BGWAS greatly reduces false positives while maintaining the same ability to detect true positive SNPs. We show the utility and flexibility of BGWAS with two case studies: a case study on salt stress in plants, and a case study on alcohol use disorder. CONCLUSIONS: BGWAS maintains and in some cases increases the recall of true SNPs while drastically lowering the number of false positives compared to popular SMA procedures.

Mapping Genetic Variation in Arabidopsis in Response to Plant Growth-Promoting Bacterium Azoarcus olearius DQS-4T.

Plant growth-promoting bacteria (PGPB) can enhance plant health by facilitating nutrient uptake, nitrogen fixation, protection from pathogens, stress tolerance and/or boosting plant productivity. The genetic determinants that drive the plant-bacteria association remain understudied. To identify genetic loci highly correlated with traits responsive to PGPB, we performed a genome-wide association study (GWAS) using an Arabidopsis thaliana population treated with Azoarcus olearius DQS-4T. Phenotypically, the 305 Arabidopsis accessions tested responded differently to bacterial treatment by improving, inhibiting, or not affecting root system or shoot traits. GWA mapping analysis identified several predicted loci associated with primary root length or root fresh weight. Two statistical analyses were performed to narrow down potential gene candidates followed by haplotype block analysis, resulting in the identification of 11 loci associated with the responsiveness of Arabidopsis root fresh weight to bacterial inoculation. Our results showed considerable variation in the ability of plants to respond to inoculation by A. olearius DQS-4T while revealing considerable complexity regarding statistically associated loci with the growth traits measured. This investigation is a promising starting point for sustainable breeding strategies for future cropping practices that may employ beneficial microbes and/or modifications of the root microbiome.

Evaluation of geranylgeranyl diphosphate synthase inhibition as a novel strategy for the treatment of osteosarcoma and Ewing sarcoma.

Rab GTPases are critical regulators of protein trafficking in the cell. To ensure proper cellular localization and function, Rab proteins must undergo a posttranslational modification, termed geranylgeranylation. In the isoprenoid biosynthesis pathway, the enzyme geranylgeranyl diphosphate synthase (GGDPS) generates the 20-carbon isoprenoid donor (geranylgeranyl pyrophosphate [GGPP]), which is utilized in the prenylation of Rab proteins. We have pursued the development of GGDPS inhibitors (GGSI) as a novel means to target Rab activity in cancer cells. Osteosarcoma (OS) and Ewing sarcoma (ES) are aggressive childhood bone cancers with stagnant survival statistics and limited treatment options. Here we show that GGSI treatment induces markers of the unfolded protein response (UPR) and triggers apoptotic cell death in a variety of OS and ES cell lines. Confirmation that these effects were secondary to cellular depletion of GGPP and disruption of Rab geranylgeranylation was confirmed via experiments using exogenous GGPP or specific geranylgeranyl transferase inhibitors. Furthermore, GGSI treatment disrupts cellular migration and invasion in vitro. Metabolomic profiles of OS and ES cell lines identify distinct changes in purine metabolism in GGSI-treated cells. Lastly, we demonstrate that GGSI treatment slows tumor growth in a mouse model of ES. Collectively, these studies support further development of GGSIs as a novel treatment for OS and ES.

Synergistic and antagonistic interactions of oxybenzone and ocean acidification: new insight into vulnerable cellular processes in non-calcifying anthozoans.

Cnidarians face significant threats from ocean acidification (OA) and anthropogenic pollutants such as oxybenzone (BP-3). The convergence of threats from multiple stressors is an important area to investigate because of potential significant synergistic or antagonistic interactions. Real-time quantitative PCR was performed to characterize the expression profiles of twenty-two genes of interest (GOI) in sea anemones (Exaiptasia diaphana) exposed to one of four treatments: 1) 96 h of OA conditions followed by a 4 h exposure to 20 ppb BP-3; 2) Exposure to 4 h 20 ppb BP-3 without 96 h of OA; 3) Exposure to 96 h of OA alone; or 4) laboratory conditions with no exposure to BP-3 and/or OA. These 22 GOIs represent cellular processes associated with proton-dependent transport, sodium-dependent transport, metal cation binding/transport, extracellular matrix, amino acid metabolism/transport, immunity, and/or steroidogenesis. These 22 GOIs provide new insight into vulnerable cellular processes in non-calcifying anthozoans exposed to OA and BP-3. Expression profiles were categorized as synergistic, antagonistic, or additive of BP-3 in the presence of OA. Two GOIs were synergistic. Fifteen GOIs were antagonistic and the remaining five GOIs were additive in response to BP-3 in acidified seawater. A subset of these GOIs appear to be candidate biomarkers for future in situ investigations. In human health, proton-dependent monocarboxylate transporters (MCTs) are promising pharmacological targets and recognized as potential biomarkers. By comparison, these same MCTs appear to be targets of xenobiotic chemical pollutants in cnidarian physiology. In the presence of BP-3, a network of collagen synthesis genes are upregulated and antagonistic in their expression profiles. Cytochrome b561 is a critical protein required for collagen synthesis and in silico modeling demonstrates BP-3 binds in the pocket of cytochrome b561. Understanding the underlying molecular mechanisms of "drug-like" compounds such as BP-3 may lead to a more comprehensive interpretation of transcriptional expression profiles. The collective antagonistic responses of GOIs associated with collagen synthesis strongly suggests these GOIs should be considered candidate biomarkers of effect. GOIs with synergistic and additive responses represent candidate biomarkers of exposure. Results show the effects of OA and BP-3 are interactive with respect to their impact on cnidarians. This investigation offers mechanistic data that supports the expression profiles and underpins higher order physiological responses.

BICOSS: Bayesian iterative conditional stochastic search for GWAS.

BACKGROUND: Single marker analysis (SMA) with linear mixed models for genome wide association studies has uncovered the contribution of genetic variants to many observed phenotypes. However, SMA has weak false discovery control. In addition, when a few variants have large effect sizes, SMA has low statistical power to detect small and medium effect sizes, leading to low recall of true causal single nucleotide polymorphisms (SNPs). RESULTS: We present the Bayesian Iterative Conditional Stochastic Search (BICOSS) method that controls false discovery rate and increases recall of variants with small and medium effect sizes. BICOSS iterates between a screening step and a Bayesian model selection step. A simulation study shows that, when compared to SMA, BICOSS dramatically reduces false discovery rate and allows for smaller effect sizes to be discovered. Finally, two real world applications show the utility and flexibility of BICOSS. CONCLUSIONS: When compared to widely used SMA, BICOSS provides higher recall of true SNPs while dramatically reducing false discovery rate.

Enhancing the Implementation of the Virtual Pediatric Trauma Center Using Practical, Robust, Implementation and Sustainability Model: A Mixed-Methods Study.

Background: This article describes factors related to adoption, implementation, and effectiveness of the Virtual Pediatric Trauma Center intervention, which uses telehealth for trauma specialist consultations for seriously injured children. We aimed at (1) measuring RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) implementation outcomes and (2) identifying PRISM (Practical, Robust, Implementation, and Sustainability Model) contextual factors that influenced the implementation outcomes. Methods: This interim implementation evaluation of our telehealth trial used a convergent mixed-methods design. The quantitative component was a cross-sectional analysis of pediatric trauma encounters using electronic health records. The qualitative component was a thematic analysis of written and verbal feedback from providers and family advisory board meetings. We compared the quantitative and qualitative data by synthesizing them in a joint display table, organized by RE-AIM dimensions. We categorized these key findings into the PRISM domains. Results: During the first 10 months of this trial, 246 subjects were randomized, with 177 assigned to standard care and 69 assigned to telehealth. Four referring sites transitioned from standard care into their intervention period. PRISM contextual factors that influenced RE-AIM implementation outcomes included the following findings: Providers struggle to remember, interpret, and navigate intervention workflows; providers have preconceived ideas about the intervention purpose; the intervention mitigates parents' anxieties about the transfer process. Discussion: This study revealed implementation challenges that influence the overall success of this telehealth trial. Early identification of these challenges allows our team the opportunity to address them now to optimize the intervention reach, adoption, and implementation. This early action will ultimately enhance the success of our trial and the ability of our intervention to achieve broad impact.

The Peptide-Drug Conjugate Melflufen Modulates the Unfolded Protein Response of Multiple Myeloma and Amyloidogenic Plasma Cells and Induces Cell Death.

Immunoglobulin light-chain (AL) amyloidosis is a rare disease caused by clonal plasma cell secretion of misfolded light chains that assemble as toxic amyloid fibrils, depositing in vital organs including the heart and kidneys, causing organ dysfunction. Plasma cell-directed therapeutics are expected to reduce production of toxic light chain by eliminating amyloidogenic cells in bone marrow, thereby diminishing amyloid fibril deposition and providing the potential for organ recovery. Melphalan flufenamide (melflufen) is a first-in-class peptide-drug conjugate that targets aminopeptidases and rapidly releases alkylating agents inside tumor cells. Melflufen is highly lipophilic, permitting rapid uptake by cells, where it is enzymatically hydrolyzed by aminopeptidases, resulting in intracellular accumulation of the alkylating agents, including melphalan. Previous data demonstrating sensitivity of myeloma cells to melflufen suggest that the drug might be useful in AL amyloidosis. We describe the effects of melflufen on amyloidogenic plasma cells in vitro and ex vivo, demonstrating enhanced cytotoxic effects in comparison to melphalan, as well as novel mechanisms of action through the unfolded protein response (UPR) pathway. These findings provide evidence that melflufen-mediated cytotoxicity extends to amyloidogenic plasma cells, and support the rationale for the evaluation of melflufen in patients with AL amyloidosis.

Recovery from opioid use disorder: A 4-year post-clinical trial outcomes study.

BACKGROUND: Opioid use disorder (OUD) seriously impacts public health in the United States. However, few investigations of long-term outcomes following treatment with medication for OUD exist. Additionally, these studies have prioritized opioid use and treatment utilization outcomes, and a gap in knowledge regarding long-term, multidimensional trajectories of OUD recovery exists. This study investigated a diverse array of outcomes for individuals with OUD at an average of 4.2 years post clinical trial participation. METHODS: Individuals who previously participated in long-acting buprenorphine subcutaneous injection clinical trials (NCT023579011; NCT025100142; NCT02896296) and enrolled in The Remission from Chronic Opioid Use-Studying Environmental and SocioEconomic Factors on Recovery (RECOVER; NCT03604861) Study participated in a follow up assessment (n = 216). Substance use, psychosocial, opioid dependence, and delay discounting outcomes were assessed. Regression analyses were conducted to determine significant associations between psychosocial/opioid dependence variables and both recent opioid use and delay discounting. RESULTS: The majority of participants reported abstinence from opioids since the last RECOVER study assessment (mean 2.26 years; 55%) and in the past 30 days (69%). Participants reported low levels of depression and psychological distress. Positive associations between depression and opioid craving with past 30-day opioid misuse and delay discounting, and negative associations between quality of life and treatment effectiveness with these outcomes were observed. CONCLUSIONS: This study examined longer term OUD recovery outcomes. Participants reported high levels of abstinence from opioids and psychosocial functioning. These encouraging results highlight the multidimensional nature of recovery from OUD, and further support the effectiveness of buprenorphine as an OUD treatment.