Key for the identification of third instar larvae of African blowflies (Diptera: Calliphoridae) of forensic importance in death investigations.

Blowfly larvae are the insects primarily responsible for the active stage of decomposition of exposed vertebrate remains and are the most frequently collected entomological evidence during forensic investigations of death. The necrophagous calliphorids in continental Africa that consistently develop on large vertebrate carrion include 11 species belonging to four genera: Calliphora, Chrysomya, Hemipyrellia and Lucilia. Most of these species are widespread in Africa and frequently reported on large animal carcasses and carrion and human corpses. A few keys have been compiled for identification of their third instar larvae, but none of them covers the complete set of taxa. Therefore, we provide a new comprehensive key with original illustrations of all taxonomically significant characters. The key is based on characters that should be easily observable even in poorly equipped local laboratories and is a reliable taxonomic tool for material collected in either urban or rural areas where synanthropic species predominate. However, it should be used with some caution in areas with relatively pristine natural habitats, where additional carrion-breeding species may occur. The publication of the key will significantly facilitate both medical and forensic entomological research and practice in Africa.

In support of morphology: Molecular analysis successfully delineates the Afrotropical genus Atylotus (Diptera: Tabanidae) into species.

Previous studies of the horse fly genus Atylotus in the Afrotropics has shown little to no differentiation into species based on the barcoding region of cytochrome oxidase I (COI), largely due to morphological misidentifications. Using field caught specimens and a museum reference collection together with type comparisons, COI and 16S ribosomal RNA sequences were generated from two specimens of Atylotus agrestis, two A. albipalpus, four A fuscipes and one A. nigromaculatus. Phylogenetic analysis of these sequences produced four separate species clades with strong support. The results showed that COI does delineate the species of Afrotropical Atylotus and that misidentifications of specimens is a common problem. Additionally, Atylotus fuscipes is revived from synonymy and given full species status. Finally, a comprehensive review of the COI barcodes, publicly available on GenBank and BOLD is included that highlights some problems with using sequences from public databases.

The Timing, Trajectory, and Incidence of Immune-Related Adverse Events in NSCLC Treated With Atezolizumab.

Introduction: Immune-related adverse events (irAEs) due to immune checkpoint inhibitors can have complicated clinical courses. We comprehensively evaluated the timing, trajectory, and incidence of both single and multiple irAEs for NSCLC treated with atezolizumab. Methods: Data were pooled from 2457 patients who participated in the IMpower130, IMpower132, and IMpower150 clinical trials investigating the use of atezolizumab in metastatic NSCLC as part of a chemoimmunotherapy regimen. Longitudinal irAE data with landmark analysis, time-to-onset, changes in grading severity, and occurrence of multiple events were summarized. Results: In general, 1557 patients were treated with atezolizumab and 900 patients were in the control groups. Median follow-up was 32.3 and 23.5 months, respectively. In the atezolizumab group, 753 patients (48.4%) experienced at least one irAE. In the control group, 289 patients (32.1%) experienced at least one nonimmune adverse event that was attributed to an irAE. In the atezolizumab group, the most common irAEs were rash, hepatitis, and hypothyroidism. Furthermore, 13% of the patients experienced two irAEs and 4% experienced three irAEs. Within 5 months of treatment, the cumulative incidence for any irAE was 39.2%. Median time-to-onset varied from 1 to 10 months based on the specific irAE. Grade 1 to 2 irAEs increased in severity for 33% of the patients. Conclusions: We identified dynamic clinical patterns for irAEs in patients treated with atezolizumab, including variations in time-to-onset, incidence of multiple irAEs, and frequency of irAEs increasing in severity. These results can guide clinical management and future reporting of adverse events to enable comprehensive longitudinal analyses.

The first reported case of accidental intestinal myiasis in a domestic dog by the flesh fly, Sarcophaga africa (Wiedeman, 1824).

Myiasis occurs when fly larvae, or maggots, feed on the tissue, secretions or digestive content of a live vertebrate. Here, a rare case of accidental intestinal or enteric myiasis is reported in a domestic dog. The species of fly is molecularly identified as Sarcophaga africa (Wiedeman, 1824) using the barcoding region of cytochrome oxidase I (COI). A brief critique on the usage of the term "pseudomyiasis" is provided and the complex taxonomy of S. africa is briefly summarised in order to shed light on the erroneous use of S. cruenata and S. haemorrhoidalis with obvious downstream effects. Finally, a comparative assessment to the limited cases in the literature is provided. These few cases are however highly fragmented and our understanding of accidental intestinal myiasis and the clinical manifestations thereof remain incomplete.

Evaluating the morphological and molecular challenges in identifying the afrotropical Atylotus species (Diptera: Tabanidae).

The Afrotropical fly genus, Atylotus has previously shown little differentiation into species groups using the barcode gene COI. This study analysed all available Atylotus COI sequences from GenBank and BOLD to determine if COI is suitable for delimiting species of this genus. Morphological assessments of the different Afrotropical species were done to determine if these species have been accurately identified in recent publications. The results show that COI does not separate the species of this genus into species clades and these species are often misidentified in the literature. This is of concern as species of this genus are known vectors of pathogens and misidentifications have serious implications for management practices. Additional genes need to be used in future molecular studies to differentiate species.

Challenges adopting next-generation sequencing in community oncology practice.

PURPOSE OF REVIEW: We are in an exhilarating time in which innovations exist to help reduce the impact of cancer for individuals, practitioners and society. Innovative tools in cancer genomics can optimize decision-making concerning appropriate drugs (alone or in combination) to cure or prolong life. The genomic characterization of tumours can also give direction to the development of novel drugs. Next-generation tumour sequencing is increasingly becoming an essential part of clinical decision-making, and, as such, will require appropriate coordination for effective adoption and delivery. RECENT FINDINGS: There are several challenges that will need to be addressed if we are to facilitate cancer genomics as part of routine community oncology practice. Recent research into this novel testing paradigm has demonstrated the barriers are at the individual level, while others are at the institution and societal levels. SUMMARY: This article, based on the authors' experience in community oncology practice and summary of literature, describes these challenges so strategies can be developed to address these challenges to improve patient outcomes.

RET rearrangements are actionable alterations in breast cancer.

Fusions involving the oncogenic gene RET have been observed in thyroid and lung cancers. Here we report RET gene alterations, including amplification, missense mutations, known fusions, novel fusions, and rearrangements in breast cancer. Their frequency, oncogenic potential, and actionability in breast cancer are described. Two out of eight RET fusions (NCOA4-RET and a novel RASGEF1A-RET fusion) and RET amplification were functionally characterized and shown to activate RET kinase and drive signaling through MAPK and PI3K pathways. These fusions and RET amplification can induce transformation of non-tumorigenic cells, support xenograft tumor formation, and render sensitivity to RET inhibition. An index case of metastatic breast cancer progressing on HER2-targeted therapy was found to have the NCOA4-RET fusion. Subsequent treatment with the RET inhibitor cabozantinib led to a rapid clinical and radiographic response. RET alterations, identified by genomic profiling, are promising therapeutic targets and are present in a subset of breast cancers.

Symptoms and Health-Related Quality of Life in Patients Receiving Cancer Therapy Matched to Genomic Profiles.

OBJECTIVES: To examine symptom occurrence and severity and overall health-related quality of life (HRQOL) in patients receiving cancer therapy guided by genomic profiling (matched therapy) and patients receiving nonmatched therapy. SAMPLE & SETTING: A retrospective and secondary analysis of data from 129 individuals with breast or gynecologic cancer receiving care at a regional outpatient cancer center. METHODS & VARIABLES: Descriptive statistics and multiple linear regression analyses were performed. Study variables included symptom occurrence and severity, HRQOL, and person- and health-/illness-related factors. Symptom occurrence and severity were measured by the Therapy-Related Symptom Checklist (TRSC), and HRQOL was measured by the HRQOL-Linear Analogue Self-Assessment. RESULTS: Individuals receiving matched therapy had lower mean TRSC scores compared to individuals receiving nonmatched therapy, but the difference was not statistically significant. HRQOL scores among individuals receiving matched therapy were not significantly higher than those receiving nonmatched therapy. Individuals with higher TRSC scores had significantly lower HRQOL. IMPLICATIONS FOR NURSING: The effects of matched therapy on an individual should be examined. Study findings are an initial step in understanding the symptom occurrence and severity and HRQOL.

Species identification of adult African blowflies (Diptera: Calliphoridae) of forensic importance.

Necrophagous blowflies can provide an excellent source of evidence for forensic entomologists and are also relevant to problems in public health, medicine, and animal health. However, access to useful information about these blowflies is constrained by the need to correctly identify the flies, and the poor availability of reliable, accessible identification tools is a serious obstacle to the development of forensic entomology in the majority of African countries. In response to this need, a high-quality key to the adults of all species of forensically relevant blowflies of Africa has been prepared, drawing on high-quality entomological materials and modern focus-stacking photomicroscopy. This new key can be easily applied by investigators inexperienced in the taxonomy of blowflies and is made available through a highly accessible online platform. Problematic diagnostic characters used in previous keys are discussed.

Down's Syndrome and Triple Negative Breast Cancer: A Rare Occurrence of Distinctive Clinical Relationship.

Down's syndrome (DS), the most common genetic cause of significant intellectual disability in children and adults is caused by the trisomy of either all or a part of human chromosome 21 (HSA21). Patients with DS mostly suffer from characteristic tumor types. Although individual patients of DS are at a higher risk for acute leukemia and testicular cancers, other types of solid tumors including breast cancers are mostly uncommon and have significantly lower-than-expected age-adjusted incidence rates. Except for an increased risk of retinoblastomas, and lymphomas, the risk of developing solid tumors has been found to be lower in both children and adults, and breast cancer was found to be almost absent (Hasle H., The Lancet Oncology, 2001). A study conducted in the United States found only one death when 11.65 were expected (Scholl T et al., Dev Med Child Neurol. 1982). A recent study examined mammogram reports of women with DS treated in the largest medical facility specifically serving adults with DS in the United States. It was found that only 0.7% women with DS had been diagnosed with breast cancers (Chicoine B et al., Intellect Dev Disabil. 2015). Here we describe a case of breast cancer in a 25-year-old patient with DS. The disease was presented as lymph node positive carcinoma with alterations of tumor suppressor genes characteristic to the triple negative breast cancer subtype. Comprehensive Genomic Profiling (CGP) revealed a wild-type status for BRCA1. The CGP report showed a frameshift mutation, A359fs*10 of the tumor suppressor gene INPP4B and another frameshift mutation, R282fs*63 of tumor suppressor gene TP53 in the tumor biopsy as characteristically found in triple-negative breast cancers. The VUS (Variance of Unknown Significance) alteration(s) were identified in ASXL1 (L1395V), NTRK1 (G18E), DDR2 (I159T), RUNX1 (amplification), ERG (amplification), SOX2 (T26A), FAM123B (G1031D), and HNF1A (A301T). Bonafide cancer-related genes of chromosome 21 amplified in the patient's tumor are RUNX1 and ERG genes. After the completion of the radiation, the patient was placed on everolimus which was based on the result of her CGP report. Thus, post-mastectomy radiation therapy was completed with a recommendation for everolimus for one year. During the time of writing of this report, no metastatic lesions were identified. The patient currently has no evidence of disease.

Utility of Genomic Analysis In Circulating Tumor DNA from Patients with Carcinoma of Unknown Primary.

Carcinoma of unknown primary (CUP) is a rare and difficult-to-treat malignancy, the management of which might be improved by the identification of actionable driver mutations. We interrogated 54 to 70 genes in 442 patients with CUP using targeted clinical-grade, next-generation sequencing of circulating tumor DNA (ctDNA). Overall, 80% of patients exhibited ctDNA alterations; 66% (290/442) ≥1 characterized alteration(s), excluding variants of unknown significance. TP53-associated genes were most commonly altered [37.8% (167/442)], followed by genes involved in the MAPK pathway [31.2% (138/442)], PI3K signaling [18.1% (80/442)], and the cell-cycle machinery [10.4% (46/442)]. Among 290 patients harboring characterized alterations, distinct genomic profiles were observed in 87.9% (255/290) of CUP cases, with 99.7% (289/290) exhibiting potentially targetable alterations. An illustrative patient with dynamic changes in ctDNA content during therapy and a responder given a checkpoint inhibitor-based regimen because of a mismatch repair gene anomaly are presented. Our results demonstrate that ctDNA evaluation is feasible in CUP and that most patients harbor a unique somatic profile with pharmacologically actionable alterations, justifying the inclusion of noninvasive liquid biopsies in next-generation clinical trials. Cancer Res; 77(16); 4238-46. ©2017 AACR.

Nocturnal oviposition behavior of blowflies (Diptera: Calliphoridae) in the southern hemisphere (South Africa and Australia) and its forensic implications.

Published research has offered contradictory evidence of the occurrence of nocturnal oviposition by carrion-breeding blowflies, a behavior that can affect the interpretation of forensic estimates of a minimum post mortem interval (minPMI) by up to 12 hours, depending on latitude and season. The majority of published studies are from the northern hemisphere. Field experiments were conducted in South Africa and Australia that extend observations to species of the southern hemisphere. Various vertebrate carrion was exposed at night in summer under different lunar phases and/or artificial lighting, and in woodland and pasture areas. Three laboratory experiments were also conducted. No nocturnal oviposition occurred outdoors in Berry, Australia, but Lucilia cuprina, Lucilia sericata and Chrysomya megacephala laid eggs outdoors at night in Grahamstown and Durban, South Africa. In laboratory experiments L. sericata, L. cuprina, Chrysomya chloropyga and Chrysomya putoria laid eggs and Calliphora augur deposited larvae under nocturnal conditions. Chrysomya albiceps and C. chloropyga laid eggs in darkness with increasing likelihood as ambient temperature increased. This study shows that nocturnal ovi/larviposition by carrion-breeding blowflies is possible in both South Africa and Australia. The forensic issue is therefore not whether nocturnal oviposition occurs, but rather whether the conditions of a particular case are more or less conducive to it. Circadian rhythms and physiological thresholds (particularly temperature and humidity) appear to act individually and in conjunction to stimulate or inhibit nocturnal laying. The significance of carcass size, freezing and handling of carcasses and comprehensive quantification for experimental design is discussed, and recommendations are made for future laboratory and case scene experiments.

Phylogenetic radiation of the greenbottle flies (Diptera, Calliphoridae, Luciliinae).

The subfamily Luciliinae is diverse and geographically widespread. Its four currently recognised genera (Dyscritomyia Grimshaw, 1901, Hemipyrellia Townsend, 1918, Hypopygiopsis Townsend 1916 and Lucilia Robineau-Desvoidy, 1830) contain species that range from saprophages to obligate parasites, but their pattern of phylogenetic diversification is unclear. The 28S rRNA, COI and Period genes of 14 species of Lucilia and Hemipyrellia were partially sequenced and analysed together with sequences of 11 further species from public databases. The molecular data confirmed molecular paraphyly in three species-pairs in Lucilia that hamper barcode identifications of those six species. Lucilia sericata and Lucilia cuprina were confirmed as mutual sister species. The placements of Dyscritomyia and Hypopygiopsis were ambiguous, since both made Lucilia paraphyletic in some analyses. Recognising Hemipyrellia as a genus consistently left Lucilia s.l. paraphyletic, and the occasionally-recognised (sub)genus Phaenicia was consistently paraphyletic, so these taxa should be synonymised with Lucilia to maintain monophyly. Analysis of a matrix of 14 morphological characters scored for adults of all genera and for most of the species included in the molecular analysis confirmed several of these findings. The different degrees of parasitism were phylogenetically clustered within this genus but did not form a graded series of evolutionary stages, and there was no particular relationship between feeding habits and biogeography. Because of the ubiquity of hybridization, introgression and incomplete lineage sorting in blow flies, we recommend that using a combination of mitochondrial and nuclear markers should be a procedural standard for medico-criminal forensic identifications of insects.

A metastatic colon adenocarcinoma harboring BRAF V600E has a durable major response to dabrafenib/trametinib and chemotherapy.

The subset of metastatic colorectal adenocarcinomas that harbor BRAF V600E mutations are aggressive tumors with significantly shortened survival and limited treatment options. Here we present a colorectal cancer patient whose disease progressed through standard chemotherapy and who developed liver metastasis. Comprehensive genomic profiling (FoundationOne(®)) identified a BRAF V600E mutation in the liver lesion, as well as other genomic alterations consistent with colorectal cancers. Combination therapy of dabrafenib and trametinib with standard cytotoxic chemotherapy resulted in a durable major ongoing response for the patient. This report illustrates the utility of comprehensive genomic profiling with personalized targeted therapy for aggressive metastatic colorectal adenocarcinomas.

Morphological identification of Lucilia sericata, Lucilia cuprina and their hybrids (Diptera, Calliphoridae).

Hybrids of Lucilia sericata and Lucilia cuprina have been shown to exist in previous studies using molecular methods, but no study has shown explicitly that these hybrids can be identified morphologically. Published morphological characters used to identify L. sericata and L. cuprina were reviewed, and then scored and tested using specimens of both species and known hybrids. Ordination by multi-dimensional scaling indicated that the species were separable, and that hybrids resembled L. cuprina, whatever their origin. Discriminant function analysis of the characters successfully separated the specimens into three unambiguous groups - L. sericata, L. cuprina and hybrids. The hybrids were morphologically similar irrespective of whether they were from an ancient introgressed lineage or more modern. This is the first evidence that hybrids of these two species can be identified from their morphology. The usefulness of the morphological characters is also discussed and photographs of several characters are included to facilitate their assessment.

Parental caregiving of children with cancer and family impact, economic burden: nursing perspectives.

Pediatric cancer diagnoses affect the entire family: parents, well siblings, the ill child, and others. The objective of this study was to review nursing studies on parental caregiving of children with cancer, family impact, and costs. The study used inclusion/exclusion criteria and family systems theory, self/dependent-care, and symptom management (monitoring, alleviation) concepts. Regarding "levels of evidence," 3 studies were Level II; 7 were Level IV; 7 were Level VI; 1 review was Level V and the second was Level I. Of 19 studies: 11 were qualitative; 4, quantitative; 2 were mixed methods. Content analysis themes were: Parental caregiving and family impact, economic burden. Conclusions were that (a) qualitative studies are predominant; findings supported quantitative findings; (b) quantitative nursing studies are less common: found one longitudinal, randomized controlled trial (RCT) focused on outcomes of an intervention for well siblings and parents, implemented by Clinical Nurse Specialists, CNSs; (c) few quantitative studies with large samples were found, especially ones with theoretical models of the family system and measures of illness impact on families; and (d) "mixed methods" longitudinal nursing research is illustrated. There is a need for "evidence-based" practice (EBP) nursing studies of interventions focused on parent education/support/assistance; respite care, and increasing family/well sibling knowledge/other information on the child's illness.

Adolescent and young adult oncology: an emerging subspecialty.

Adolescent and young adult (AYA) oncology is caught between the pediatric and adult oncology settings and, therefore, poorly defined. Unfortunately, progress in overall survival for this age cohort has been stagnant while children and older adults have seen significant improvements. Reasons for the lack of progress are multifactorial, with biologic and psychosocial explanations. The current article will detail the unique features of AYA patients with cancer in terms of outcomes, psychosocial issues, and recommendations. Literature pertaining to AYA patients with cancer from 2006-2012 was reviewed. Findings suggested that recognizing AYAs as a subspecialty that requires holistic, multidisciplinary care may improve outcomes. Nurses at all levels are adept at providing holistic care and are, therefore, excellent potential advocates for a specialized care delivery model that AYAs with cancer deserve.

An intervention to manage patient-reported symptoms during cancer treatment.

Patients with cancer receiving therapy may face a variety of complicated and stressful symptoms. Oncology nurses can advocate for patients by performing their roles as educators and comanagers of cancer-related side effects. In addition, symptom-focused education provided by oncology nurses can enable patients to administer self-care more effectively.

An accidental but safe and effective use of Lucilia cuprina (Diptera: Calliphoridae) in maggot debridement therapy in Alexandria, Egypt.

The calliphorid fly, Lucilia cuprina (Wiedemann), is known to cause serious malign myiasis in animals, whereas its sibling species Lucilia sericata (Meigen) is commonly a carrion breeder and is used in maggot debridement therapy (MDT). The current study reports an accidental involvement of L. cuprina in MDT in Alexandria, Egypt, that has proved to be safe and effective. In November 2008, the laboratory colonies of L. sericata (the species regularly used in MDT) at the Faculty of Science, Alexandria University were renewed by Lucilia flies collected as third instar larvae on exposed rabbit carcasses. Flies from the new colonies were successfully used to heal the diabetic foot wounds of two patients at Alexandria Main University Hospital. Analysis of DNA sequences and adult and larval morphology then revealed that these flies were and still are L. cuprina. Breeding of this species in carrion in Alexandria is a new record. Despite the safety of this strain of L. cuprina in MDT, entomologists rearing blow flies for the purpose of wound debridement should regularly maintain high quality assurance of their species' identity to avoid possible clinical complications that may result from the introduction of an unexpected and invasive species to their laboratory colonies.