Systematic discovery of neoepitope-HLA pairs for neoantigens shared among patients and tumor types.

The broad application of precision cancer immunotherapies is limited by the number of validated neoepitopes that are common among patients or tumor types. To expand the known repertoire of shared neoantigen-human leukocyte antigen (HLA) complexes, we developed a high-throughput platform that coupled an in vitro peptide-HLA binding assay with engineered cellular models expressing individual HLA alleles in combination with a concatenated transgene harboring 47 common cancer neoantigens. From more than 24,000 possible neoepitope-HLA combinations, biochemical and computational assessment yielded 844 unique candidates, of which 86 were verified after immunoprecipitation mass spectrometry analyses of engineered, monoallelic cell lines. To evaluate the potential for immunogenicity, we identified T cell receptors that recognized select neoepitope-HLA pairs and elicited a response after introduction into human T cells. These cellular systems and our data on therapeutically relevant neoepitopes in their HLA contexts will aid researchers studying antigen processing as well as neoepitope targeting therapies.

Thumb Metacarpophalangeal Joint Ulnar Collateral Ligament Injuries: Management and Biomechanical Evaluation.

First described in 1955 as "gamekeeper's thumb," injuries to the ulnar collateral ligament (UCL) of the thumb metacarpophalangeal joint are common and can cause pain and instability, especially during key pinch and grasp. Although primarily diagnosed on physical examination, stress radiographs, ultrasonography, and magnetic resonance imaging can be used to diagnose UCL injuries and distinguish partial from complete tears. If complete rupture occurs, the adductor aponeurosis can become interposed between the retracted UCL stump and its insertion on the proximal phalanx, known as a "Stener lesion." When instability persists after a trial of nonsurgical management or in the setting of complete rupture, there are various methods of repair or reconstruction. Biomechanically, there are no treatments of repair or reconstruction using native tissues that provide equivalent strength to the preinjured ligament. Recently, suture tape augmentation has been used for the repair or reconstruction with excellent short-term results and earlier return to function, although there is a paucity of literature on longer term outcomes. The various methods of surgical treatment yield excellent outcomes with a low incidence of complications.

Two Parallel Headless Compression Screws for Scaphoid Fractures: Radiographic Analysis and Preliminary Outcome.

BACKGROUND: Despite surgical fixation, the scaphoid nonunion rate remains at 3% to 5%. Recent biomechanical studies have demonstrated increased stability with 2-screw constructs. The objective of our study is to determine the preliminary union rate and anatomic feasibility of 2-screw surgical fixation for scaphoid fractures. METHODS: This study is a retrospective case series of 25 patients (average age 32 years) with scaphoid fractures treated with 2 parallel headless compression screws (HCS). Postoperative evaluation included Mayo Wrist Score (MWS), range of motion, time to union, and return to activity. Bivariate analysis for gender and Pearson correlation coefficient for body size (height, weight, and body mass index) was conducted against radiographically measured scaphoid width, screw lengths, and the distance between the 2 screws. RESULTS: All fractures healed with an average time to union of 9.9 weeks (median 7.6 weeks; range: 4.1-28.3). The mean MWS was 93.3 (range: 55-100), with 3 complications (12%), one of which affected the outcome of the surgery. The bivariate analysis demonstrated that the female gender was associated with significantly smaller scaphoid width (P = .004) but a similar distance between the 2 screws (P = .281). The distance between the 2 screws and the body size demonstrated a weak-to-no correlation. CONCLUSIONS: The 2-screw construct for scaphoid fracture achieved a favorable union rate and clinical outcome. Gender was the only variable significantly associated with scaphoid width and screw length. The distance between the screws was constant regardless of gender and body size, indicating that the technique for parallel screw placement can remain consistent. TYPE OF STUDY: Therapeutic. LEVEL OF EVIDENCE: Level IV.

Tissue-specific mitochondrial HIGD1C promotes oxygen sensitivity in carotid body chemoreceptors.

Mammalian carotid body arterial chemoreceptors function as an early warning system for hypoxia, triggering acute life-saving arousal and cardiorespiratory reflexes. To serve this role, carotid body glomus cells are highly sensitive to decreases in oxygen availability. While the mitochondria and plasma membrane signaling proteins have been implicated in oxygen sensing by glomus cells, the mechanism underlying their mitochondrial sensitivity to hypoxia compared to other cells is unknown. Here, we identify HIGD1C, a novel hypoxia-inducible gene domain factor isoform, as an electron transport chain complex IV-interacting protein that is almost exclusively expressed in the carotid body and is therefore not generally necessary for mitochondrial function. Importantly, HIGD1C is required for carotid body oxygen sensing and enhances complex IV sensitivity to hypoxia. Thus, we propose that HIGD1C promotes exquisite oxygen sensing by the carotid body, illustrating how specialized mitochondria can be used as sentinels of metabolic stress to elicit essential adaptive behaviors.

Pediatric genitourinary tumors: Distribution, demographics, and outcomes.

Importance: The diversity of pediatric genitourinary malignancies requires a timely resource detailing tumor characteristics and survival. Objective: To determine the incidence, demographics, and outcomes of all pediatric genitourinary tumors within the United States. Methods: A population-based search for patients diagnosed with genitourinary cancers under age 15 was performed using the National Cancer Institute's Surveillance, Epidemiology, and End Results 18 registry. Information on primary tumor location, histologic type, patient age, sex, year of diagnosis, race, treatment, cause of death, and survival months was extracted. Descriptive epidemiological and survival statistics were calculated for all variables. Results: A total of 4576 cases from 1973 through 2015 were identified. The most common primary tumor sites were the kidney (80.3%), testis (12.3%), bladder (2.8%), and vagina (1.5%). Nephroblastoma (87.9%) and sarcoma (3.4%) were the most common renal malignancies. Rhabdomyosarcoma was common in the vagina, bladder, and testis at rates of 66.2%, 61.2%, and 24.6%, respectively. Germ cell tumors (71.0%) were the most common primary tumor of the testis. Ten-year overall survival (OS) for renal nephroblastoma and sarcoma was 88% and 82%, respectively. Ten-year OS for RMS of the testis was 91%, the bladder was 79%, the vagina was 79%, and the prostate was 56%. Germ cell tumor 10-year OS were 96% in the testis and 100% in the vagina. Interpretation: A better understanding of the overall distribution and outcomes associated with pediatric genitourinary cancers allows physicians to best understand the patient's disease in the context of current frequency in a genitourinary setting and reported outcomes.

Stanniocalcin2, but Not Stanniocalcin1, Responds to Hypoxia in a HIF1-Dependent Manner in the Retina.

The quest for neuroprotective factors that can prevent or slow down the progression of retinal degeneration is still ongoing. Acute hypoxic stress has been shown to provide transient protection against subsequent damage in the retina. Stanniocalcins - STC1 and STC2 - are secreted glycoproteins that are hypoxia-regulated and were shown to be cytoprotective in various in vitro studies. Hence, we investigated the expression of stanniocalcins in the normal, degenerating and hypoxic retina. We show that the expression of Stc1 and Stc2 in the retina was detectable as early as postnatal day 10 and persisted during aging. Retinal expression of Stc2, but not Stc1, was induced in mice in an in vivo model of acute hypoxia and a genetic model of chronic hypoxia. Furthermore, we show that HIF1, not HIF2, is responsible for regulating Stc2 in cells with the molecular response to hypoxia activated due to the absence of von Hippel Lindau protein. Surprisingly, Stc2 was not normally expressed in photoreceptors but in the inner retina, as shown by laser capture microdissection and immunofluorescence data. The expression of both Stc1 and Stc2 remained unchanged in the degenerative retina with an almost complete loss of photoreceptors, confirming their expression in the inner retina. However, the absence of either Stc1 or Stc2 had no effect on retinal architecture, as was evident from retinal morphology of the respective knockout mice. Taken together our data provides evidence for the differential regulation of STC1 and STC2 in the retina and the prospect of investigating STC2 as a retinal neuroprotective factor.

Continued use of scrotal ultrasounds for the workup of undescended testes: Confirmation bias and inaccuracies.

AIM: Scrotal ultrasounds are utilised in some primary care settings for suspected cryptorchidism, despite inaccuracies. We aim to identify the correlation between ultrasound and primary care provider (PCP) findings of undescended testicles (UDTs) as a potential source of confirmation bias. METHODS: Males referred for suspected UDT by PCPs who underwent scrotal ultrasound and paediatric urologist examination from 2014 to 2019 were included. Correlation between PCP and ultrasound findings and diagnostic accuracy were evaluated. Logistic regression was utilised to determine associations between patient factors and UDT misdiagnosis. RESULTS: Out of 145 testes, ultrasound corroborated PCPs' UDT diagnoses 87.6% of the time, 49.6% of which were confirmed as UDT by paediatric urologists. Ultrasound had a false positivity rate of 81.0% and specificity of 19.0%. Ultrasound versus paediatric urologist findings regarding testicle location were significantly different (P < 0.0001). Patients aged ≥8 years old had 5.2 times greater odds of being misdiagnosed with UDT than patients <8 years old (95% confidence interval: 1.6-16.7; P < 0.002) by PCP and ultrasound. CONCLUSION: Scrotal ultrasound highly corroborated PCPs' UDT diagnoses. Older patients were more likely to be misdiagnosed with UDT by PCP and ultrasound. As ultrasounds rarely refute PCP examinations for suspected UDTs and are highly inaccurate, confirmation bias may explain the use of ultrasound in the workup of UDT.

Rapid debromination of tetrabromobisphenol A by Cu/Fe bimetallic nanoparticles in water, its mechanisms, and genotoxicity after treatments.

Tetrabromobisphenol A (TBBPA), a widely used brominated flame retardants, has been detected in various environmental matrices and is known to cause various adverse effects on human bodies. This study examined the feasibility and effectiveness of remediating TBBPA using Cu/Fe bimetallic nanoparticles (Cu/Fe BNPs) at various environmental and operational conditions. In general, TBBPA removal rate and debromination efficiency increased with higher Cu doping, higher Cu/Fe BNPs loading, higher temperature, and lower pH. At optimal conditions, TBBPA was completed removed at a rate constant > 0.2 min-1 where over 90% TBBPA was transformed to BPA within 30 min. The activation energy was found to be 35.6 kJ/mol, indicating that TBBPA was predominantly removed via surface-controlled reactions. Under pH 3-7 and ≥ 25 °C, debromination was the dominant removal mechanism compared to adsorption. The complete debromination pathway and the time-evolution of intermediates byproducts at different pHs were also presented. Cu/Fe BNPs can be reused for more than 6 times with performance constancy. Genotoxic tests showed that the treated solution did not find a significant hazardous potential. The byproducts can be further degraded by additional H2O2 through Fenton reaction. These results demonstrated the efficacy of Cu/Fe BNPs for treating TBBPA and its potential for degrading other halogenated organic compounds.

Persistent Anhydramnios and Lower Urinary Tract Obstruction in a Patient With a Vesicoamniotic Shunt.

Persistent anhydramnios after placement of a vesicoamniotic shunt is a rare but potentially serious concern in a patient in utero. We present the case a male fetus who at 32-week gestation had bilateral hydroureteronephrosis, a distended bladder, and anhydramnios. A vesicoamniotic shunt was placed, but the anhydramnios persisted. Postnatally, the child was found to have a migrated shunt, left grade V vesicoureteral reflux and posterior urethral valves. He underwent a posterior urethral valves ablation and removal of the migrated shunt. The patient is now 2 years old and is doing well with no urinary tract infections or renal deterioration.

Association of Regular Leisure-Time Physical Activity with Self-Reported Body Mass Index and Obesity Risk among Middle-Aged and Older Adults in Taiwan.

Through this study, we aimed to determine the association of regular leisure-time physical activity (LTPA) with self-reported body mass index (BMI) and obesity risk among middle-aged and older adults in Taiwan. We conducted a cross-sectional study and reviewed the data derived from the Taiwan National Physical Activity Survey (TNPAS). Responses from 12,687 participants aged 45-108 years from the database were collected in this study. All the participants completed a standardized structured questionnaire that solicitated information regarding their demographic characteristics (age, gender, education, occupation, and self-reported health status), physical activity behaviors (regular/nonregular LTPA), and self-reported anthropometrics (height, weight, and BMI). Multiple linear and logistic regressions were used to examine the association between regular LTPA and BMI, and between regular LTPA and obesity status, respectively. Regular LTPA was associated with male gender, normal weight, excellent or good self-reported health status, and a lower rate of being underweight compared with nonregular LTPA. Regular LTPA was significant negatively associated with being underweight (OR = 0.71, p < 0.05), whereas it had no significant relationship with BMI and obesity (p > 0.05). Regular LTPA was associated with a reduced risk of being underweight among middle-aged and elderly adults in Taiwan. Further research on the relevant mechanism underlying this phenomenon is warranted.

Association between severity of prenatally diagnosed hydronephrosis and receipt of surgical intervention postnatally among patients seen at a fetal-maternal center.

BACKGROUND: Hydronephrosis (HN) is the most common abnormality detected on prenatal ultrasound. This study sought to stratify outcomes of patients by severity of prenatal HN with postnatal outcomes. METHODS: This was a retrospective review of patients referred to a tertiary care fetal-maternal clinic with diagnosis of prenatal HN from 2004 to 2019. HN severity was categorized as mild, moderate, or severe. Data were analyzed to determine the association between HN severity and surgical intervention. Decision for surgery was based on factors including history of multiple urinary tract infections, evidence of renal scarring, and/or reduced renal function. Surgery-free survival time was represented by the Kaplan-Meier method, and hazard ratios were calculated using the log-rank test. RESULTS: 131 kidneys among 101 infants were prenatally diagnosed with hydronephrosis; 35.9% had mild HN, 29.0% had moderate HN, and 35.1% had severe HN. 8.5% of patients with mild HN, 26.3% of patients with moderate HN, and 65.2% of patients with severe HN required surgery. Patients with severe HN were 12.2 (95% CI 6.1-24.4; p < 0.001) times more likely to undergo surgery for HN than patients with mild HN and 2.9 (95% CI 1.5-5.3; p = 0.003) times more likely to undergo surgery than patients with moderate HN. Patients with moderate HN were 4.3 times more likely to require surgery than patients with mild HN (95% CI 1.5-12.9; p = 0.01). Median age at surgery was 11.8 months among patients with mild HN (IQR 11.7-14.1 months), 6.6 months among patients with moderate HN (IQR 4.2-16.4 months), and 5.4 months among patients with severe HN (3.7-12.4 months). CONCLUSION: Among this cohort of referrals from a fetal-maternal clinic, severity of HN correlated with increased likelihood of surgical intervention. Continued assessment of patients with prenatal HN should be evaluated to best determine the role of the pediatric urologist in cases of prenatal HN.

Robotic adrenalectomy in the pediatric population: initial experience case series from a tertiary center.

BACKGROUND: Laparoscopic resection is the most well described minimally-invasive approach for adrenalectomy. While it allows for improved cosmesis, faster recovery and decreased length of hospital stay compared with the open approach, instrument articulation limitations can hamper surgical dexterity in pediatric patients. Use of robotic assistance can greatly enhance operative field visualization and instrument control, and is in the early stages of adoption in academic centers for pediatric populations. CASE PRESENTATION: We present a single-institution series of pediatric adrenalectomy cases. The da Vinci Xi surgical system was used to perform adrenalectomies on three consecutive patients (ages, 2-13 years) at our center. Final pathology revealed ganglioneuroblastoma (n = 2) and pheochromocytoma (n = 1). Median operating time was 244 min (range, 244-265 min); median blood loss was estimated at 100 ml (range, 15-175 ml). Specimens were delivered intact and all margins were negative. Median post-operative hospital stay was 2 days (range, 1-6 days). All patients remain disease-free at median follow-up of 19 months (range, 12-30 months). CONCLUSION: Our experience continues to evolve, and suggests that robotic surgery is safe, feasible and oncologically effective for resection of adrenal masses in well-selected pediatric patients.

Surgical Approach and Internal Fixation Techniques for Intra-Articular Distal Humerus Fracture With Coronal Shear Capitellar Fracture.

Intra-articular distal humerus fractures with an associated coronal shear capitellar fragment present a challenge for stable internal fixation. Adequate visualization and fixation of the capitellar shear fragment are difficult to achieve with conventional exposures, including the olecranon osteotomy. The capitellar fragment often translates anterior and proximally and is challenging to visualize with intact soft tissue attachments from a posterior approach. We describe a surgical exposure that releases the lateral ulnar collateral ligament in addition to an olecranon osteotomy to allow complete visualization of the entire articular surface. In contrast to an isolated capitellar fracture, the column stability and the posterior cortex are frequently disrupted with distal humerus fractures. Depending on the comminution of the posterior cortex, a supplemental posterolateral plate or headless compression screws can provide fixation to the coronal fracture plane. The lateral ulnar collateral ligament is repaired at the conclusion of fracture stabilization through a bone tunnel or to the plate to restore lateral stability. Despite the release of the ligament and additional soft tissue stripping, there were no cases of elbow instability or avascular necrosis in our case series of 9 patients.

Anomalous Courses of the Palmar Cutaneous Branch of the Median Nerve in Relation to the Flexor Carpi Radialis Tendon for ORIF of Distal Radius Fractures.

Background: The purpose of this study was to prospectively document the incidence of variations in the course of palmar cutaneous branch of the median nerve (PCBMN) that may increase the risk of injury to the nerve during the flexor carpi radialis (FCR) approach. We hypothesize that the incidence of anomalous branching of the PCBMN around the FCR sheath will be approximately 5%. Methods: All cases that met inclusion criteria between November 2013 and March 2018 were included. The operating surgeon made the final decision for operative intervention using the FCR approach. Each surgeon performed the standard FCR approach to the distal radius. The branching location from the median nerve, the relationship to the FCR sheath, and the course of the PCBMN were recorded. Results: In total, 101 distal radius fractures were included. The average branching point of PCBMN was 5.2 cm from the distal wrist crease (range = 3.3-9.0). There were 26 anomalous branching patterns of PCBMN. Nineteen (18.8%) crossed volar, dorsal, or ran within the FCR sheath. Six PCBMN were found within the FCR sheath, 1 penetrated the FCR sheath, 6 crossed volar to the FCR sheath, and 6 were dorsal to the FCR tendon sheath. When comparing the branching patterns of the PCBMN from the median nerve, 4 branched from the volar aspect, 2 branched from the dorsal aspect, and 1 branched from the ulnar aspect of the median nerve. Conclusions: Variation in the course of the PCBMN relative to the FCR sheath is more than previously thought and can be expected in approximately 18.8% of patients.

Carvedilol inhibits EGF-mediated JB6 P+ colony formation through a mechanism independent of adrenoceptors.

Carvedilol is reported to prevent cancers in humans and animal models. However, a molecular mechanism has yet to be established, and the extent to which other ß-blockers are chemopreventive remains relatively unknown. A comparative pharmacological approach was utilized with the expectation that a mechanism of action could be devised. JB6 Cl 41-5a (JB6 P+) murine epidermal cells were used to elucidate the chemopreventative properties of ß-blockers, as JB6 P+ cells recapitulate in vivo tumor promotion and chemoprevention. The initial hypothesis was that ß-blockers that are GRK/ß-arrestin biased agonists, like carvedilol, are chemopreventive. Sixteen ß-blockers of different classes, isoproterenol, and HEAT HCl were individually co-administered with epidermal growth factor (EGF) to JB6 P+ cells to examine the chemopreventative properties of each ligand. Cytotoxicity was examined to ensure that the anti-transformation effects of each ligand were not due to cellular growth inhibition. Many of the examined ß-blockers suppressed EGF-induced JB6 P+ cell transformation in a non-cytotoxic and concentration-dependent manner. However, the IC50 values are high for the most potent inhibitors (243, 326, and 431 nM for carvedilol, labetalol, and alprenolol, respectively) and there is no correlation between pharmacological properties and inhibition of transformation. Therefore, the role of α1- and ß2-adrenergic receptors (AR) was examined by standard competition assays and shRNA targeting ß2-ARs, the only ß-AR expressed in JB6 P+ cells. The results reveal that pharmacological inhibition of α1- and ß2-ARs and genetic knockdown of ß2-ARs did not abrogate carvedilol-mediated inhibition of EGF-induced JB6 P+ cell transformation. Furthermore, topical administration of carvedilol protected mice from UV-induced skin damage, while genetic ablation of ß2-ARs increased carvedilol-mediated effects. Therefore, the prevailing hypothesis that the chemopreventive property of carvedilol is mediated through ß-ARs is not supported by this data.

Light-Activated Tissue-Integrating Sutures as Surgical Nanodevices.

Sutures are typically the primary means of soft tissue repair in surgery and trauma. Despite their widespread use, sutures do not result in immediate sealing of approximated tissues, which can result in bacterial infection and leakage. Nonabsorbable sutures and staples can be traumatic to tissue, and the trauma can be exacerbated by their subsequent removal. Use of cyanoacrylate glues is limited because of their brittleness and toxicity. In this work, laser-activated tissue-integrating sutures (LATIS) are described as novel nanodevices for soft tissue approximation and repair. Incorporation of gold nanorods within fibers generated from collagen result in LATIS fibers which demonstrate robust photothermal responses following irradiation with near infrared laser light. Compared to conventional sutures, LATIS fibers result in greater biomechanical recovery of incised skin in a mouse model of skin closure after spine surgeries. Histopathology analyses show improved repair of the epidermal gap in skin, which indicate faster tissue recovery using LATIS. The studies indicate that LATIS-facilitated approximation of skin in live mice synergizes the benefits of conventional suturing and laser-activated tissue integration, resulting in new approaches for faster sealing, tissue repair, and healing.

Long-Term Follow-up of Capsular Interposition Arthroplasty for Hallux Rigidus.

BACKGROUND: Capsular interposition arthroplasty is a joint- and motion-sparing procedure that has been shown as an effective alternative to fusion. This study aimed to evaluate patient function and satisfaction after long-term follow-up. METHODS: Sixty-four patients were treated with capsular interposition arthroplasty for hallux rigidus by the senior author performed between February 1998 and July 2011. Twenty-two patients could not be reached for follow-up and were thus excluded from the analysis. Therefore, 42 remaining patients were evaluated using the visual analog scale (VAS), Foot Function Index (FFI), Short Form 12 (SF-12), and patient satisfaction scores. The mean follow-up was 11.3 (range, 4-16) years. RESULTS: The mean VAS for pain was 7.9 preoperatively and 1.8 postoperatively ( P = .003). The mean preoperative SF-12 physical score was 42.0 vs 64.2 postoperatively ( P = .02). The mean preoperative SF-12 mental score was 50.7, while the postoperative SF-12 mental score was 54.6 ( P = .01). The total FFI score also significantly improved, with a preoperative value of 98.3 and a postoperative mean score of 49.6 ( P = .001). The mean patient satisfaction score was 7.4 of 10. Overall, 39 of 42 patients (92.9%) stated they would have the surgery again. Four of the 42 patients (9.5%) required conversion to hallux metatarsophalangeal fusion at a mean of 6.1 years after the index procedure secondary to pain, but no other complications were reported. CONCLUSION: Capsular interposition arthroplasty was a safe and effective treatment for severe hallux rigidus. These longer term results demonstrate a high level of patient satisfaction. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Acute oxygen sensing by the carotid body: from mitochondria to plasma membrane.

Maintaining oxygen homeostasis is crucial to the survival of animals. Mammals respond acutely to changes in blood oxygen levels by modulating cardiopulmonary function. The major sensor of blood oxygen that regulates breathing is the carotid body (CB), a small chemosensory organ located at the carotid bifurcation. When arterial blood oxygen levels drop in hypoxia, neuroendocrine cells in the CB called glomus cells are activated to signal to afferent nerves that project to the brain stem. The mechanism by which hypoxia stimulates CB sensory activity has been the subject of many studies over the past 90 years. Two discrete models emerged that argue for the seat of oxygen sensing to lie either in the plasma membrane or mitochondria of CB cells. Recent studies are bridging the gap between these models by identifying hypoxic signals generated by changes in mitochondrial function in the CB that can be sensed by plasma membrane proteins on glomus cells. The CB is important for physiological adaptation to hypoxia, and its dysfunction contributes to sympathetic hyperactivity in common conditions such as sleep-disordered breathing, chronic heart failure, and insulin resistance. Understanding the basic mechanism of oxygen sensing in the CB could allow us to develop strategies to target this organ for therapy. In this short review, I will describe two historical models of CB oxygen sensing and new findings that are integrating these models.