Verteporfin synergizes the efficacy of anti-PD-1 in cholangiocarcinoma.

BACKGROUND: Cholangiocarcinoma (CCA) is one of the primary hepatobiliary malignant neoplasms with only 10% of 5-year survival rate. Promising immunotherapy with the blockade of immune checkpoints has no clear benefit in CCA. The inhibition of YAP1 signaling by verteporfin has shown encouraging results by inhibiting cell proliferation and inducing apoptosis. This study aimed to evaluate the potential benefit of the combination of verteporfin and anti-programmed cell death 1 (PD-1) in CCA mouse model. METHODS: We assessed the cytotoxicity of verteporfin in human CCA cell lines in vitro, including both intrahepatic CCA and extrahepatic CCA cells. We examined the in vitro effect of verteporfin on cell proliferation, apoptosis, and stemness. We evaluated the in vivo efficacy of verteporfin, anti-PD-1, and a combination of both in subcutaneous CCA mouse model. RESULTS: Our study showed that verteporfin reduced tumor cell growth and enhanced apoptosis of human CCA tumor cells in vitro in a dose-dependent fashion. Nevertheless, verteporfin impaired stemness evidenced by reduced spheroid formation and colony formation, decreased numbers of cells with aldehyde dehydrogenase activity and positive cancer stem cell markers (all P < 0.05). The combination of verteporfin and anti-PD-1 reduced tumor burden in CCA subcutaneous SB1 tumor model compared to either agent alone. CONCLUSIONS: Verteporfin exhibits antitumor effects in both intrahepatic and extrahepatic CCA cell lines and the combination with anti-PD-1 inhibited tumor growth.

Isolated gluteal and paravertebral muscle weakness due to anti-3-hydroxy-3-methylglutaryl-coenzyme a reductase antibody-associated necrotizing autoimmune myopathy.

INTRODUCTION: A 56-year-old man with a distant history of statin use presented with progressive isolated very proximal lower limb and truncal weakness. Electromyogram (EMG) showed isolated gluteal and lumbar paraspinal muscle involvement. METHODS: Gluteus medius muscle biopsy was performed under general anesthesia. RESULTS: The biopsy showed a pauci-inflammatory necrotizing myopathy. Serum antibodies to 3-hydroxy-3-methylglutaryl-coenzyme A reductase (HMGCR) were positive. He has since partially responded to corticosteroids and methotrexate. CONCLUSIONS: Anti-HMGCR-associated necrotizing autoimmune myopathy (NAM) can present in a restricted form after cessation of a statin. Biopsy of a symptomatic but uncommonly studied muscle is worthwhile. Muscle Nerve 54: 150-152, 2016.

Defects of mutant DNMT1 are linked to a spectrum of neurological disorders.

We report a broader than previously appreciated clinical spectrum for hereditary sensory and autonomic neuropathy type 1E (HSAN1E) and a potential pathogenic mechanism for DNA methyltransferase (DNMT1) mutations. The clinical presentations and genetic characteristics of nine newly identified HSAN1E kinships (45 affected subjects) were investigated. Five novel mutations of DNMT1 were discovered; p.C353F, p.T481P, p.P491L, p.Y524D and p.I531N, all within the target-sequence domain, and two mutations (p.T481P, p.P491L) arising de novo. Recently, HSAN1E has been suggested as an allelic disorder of autosomal dominant cerebellar ataxia, deafness and narcolepsy. Our results indicate that all the mutations causal for HSAN1E are located in the middle part or N-terminus end of the TS domain, whereas all the mutations causal for autosomal dominant cerebellar ataxia, deafness and narcolepsy are located in the C-terminus end of the TS domain. The impact of the seven causal mutations in this cohort was studied by cellular localization experiments. The binding efficiency of the mutant DNMT proteins at the replication foci and heterochromatin were evaluated. Phenotypic characterizations included electromyography, brain magnetic resonance and nuclear imaging, electroencephalography, sural nerve biopsies, sleep evaluation and neuropsychometric testing. The average survival of HSAN1E was 53.6 years. [standard deviation = 7.7, range 43-75 years], and mean onset age was 37.7 years. (standard deviation = 8.6, range 18-51 years). Expanded phenotypes include myoclonic seizures, auditory or visual hallucinations, and renal failure. Hypersomnia, rapid eye movement sleep disorder and/or narcolepsy were identified in 11 subjects. Global brain atrophy was found in 12 of 14 who had brain MRI. EEGs showed low frequency (delta waves) frontal-predominant abnormality in five of six patients. Marked variability in cognitive deficits was observed, but the majority of patients (89%) developed significant cognitive deficit by the age of 45 years. Cognitive function decline often started with personality changes and psychiatric manifestations. A triad of hearing loss, sensory neuropathy and cognitive decline remains as the stereotypic presentation of HSAN1E. Moreover, we show that mutant DNMT1 proteins translocate to the cytoplasm and are prone to form aggresomes while losing their binding ability to heterochromatin during the G2 cell cycle. Our results suggest mutations in DNMT1 result in imbalanced protein homeostasis through aggresome-induced autophagy. This mechanism may explain why mutations in the sole DNA maintenance methyltransferase lead to selective central and peripheral neurodegeneration.

New Zealand National GDM Guidelines: an alternative view of some good practice points.

The New Zealand Gestational Diabetes Mellitus (GDM) Guidelines, commissioned by the Ministry of Health, contains many good points, but several recommendations are creating controversy. This opinion piece discusses an alternative approach to early pregnancy screening for diabetes. We suggest that it is reasonable to refer women with an HbA1c ≥41 mmol/mol (5.9%) for further management, rather than the recommended referral threshold of ≥50 mmol/mol (6.7%). We also suggest that, for subsequent screening for GDM at 24-28 weeks' gestation, a 75 g oral glucose tolerance test should be offered rather than a 50 g glucose challenge test.

Immediate Postoperative Change in the Upper Instrumented Screw-Vertebra Angle Is a Predictor for Proximal Junctional Kyphosis and Failure.

STUDY DESIGN: Retrospective review. OBJECTIVES: To determine if change in position of upper instrumented vertebral (UIV) screw between intraoperative prone and immediate postoperative standing radiographs is a predictor for proximal junctional kyphosis or failure (PJK/PJF). SUMMARY OF BACKGROUND DATA: Cranially directed UIV screws on post-operative radiographs have been found to be associated with PJK. Change in the screw position between intraoperative and immediate postoperative radiographs has not been studied. METHODS: Patients with posterior fusion ≥3 levels and UIV at or distal to T8, and minimum 2-year follow-up were identified from a single center database. Primary outcomes were radiographic PJK/PJF or revision for PJK/PJF. Demographic, surgical and radiographic variables, including intraoperative screw-vertebra (S-V) angle, change in S-V angle, direction of UIV screw (cranial-neutral-caudal) and rod-vertebra (R-V) angle were collected. RESULTS: 143 cases from 110 patients were included with a mean age of 62.9 years and a follow-up of 3.5 years. 54 (38%) cases developed PJK/PJF, of whom 30 required a revision. Mean S-V angle was -0.9°±5.5° intraoperative and -2.8°±5.5° postoperative. The group with PJK/PJF had a mean S-V angle change of -2.5°±2.4 while the rest had a change of -1.0°±1.6 (P=0.010). When the change in S-V angle was <5°, 33% developed PJK, this increased to 80% when it was ≥5° (P=0.001). Revision for PJK/PJF increased from 16% to 60% when S-V angle changed ≥5° (P=0.001). Regression analysis showed S-V angle change as a significant risk factor for PJK/PJF (P=0.047, OR=1.58) and for revision due to PJK/PJF (P=0.009, OR=2.21). CONCLUSIONS: Change in the S-V angle from intraop prone to immediate postop standing radiograph is a strong predictor for PJK/PJF and for revision. For each degree of S-V angle change, odds of revision for PJK/PJF increases by 2.2x. A change of 5° should alert the surgeon to the likely development of PJK/PJF requiring revision.

Teaching old presumptive tests new digital tricks with computer vision for forensic applications.

Presumptive (or 'spot') tests have served forensic scientists, law enforcement, and legal practitioners for over a hundred years. Yet, the intended design of such tests, enabling quick identification of drugs by-eye, also hides their full potential. Here, we report the development and application of time-resolved imaging methods of reactions attending spot tests for amphetamines, barbiturates, and benzodiazepines. Analysis of the reaction videos helps distinguish drugs within the same structural class that, by-eye, are judged to give the same qualitative spot test result. It is envisaged that application of these results will bridge the existing suite of field and lab-based confirmatory forensic tests, and support a broader range of colorimetric sensing technologies.

Diabetes mellitus prevalence in Northland New Zealand schizophrenia patients on clozapine.

AIMS: Clozapine is a unique atypical anti-psychotic agent with best efficacy for treatment resistant schizophrenia compared to other agents, but with increased metabolic adverse effects. We sought to audit the prevalence of diabetes and pre-diabetes in Northland, New Zealand patients on clozapine. METHOD: We captured all 287 patients in Northland, New Zealand who were prescribed clozapine in September 2021 and obtained demographic, clinical and laboratory data. RESULTS: We discovered that 26.48% had diabetes (one patient type one, 75 type two diabetes) and 14.63% had pre-diabetes that developed after a median of six years' clozapine treatment. Diabetes prevalence is approximately 6% in the general population. NZ Maori made up 65.85% of the entire cohort (35.8% of the general population) and 85.53% of the diabetes patients. NZ Europeans represented most of the remaining 30.66% on clozapine, consistent with the largely bicultural ethnic mix of our region. Maori on clozapine were younger: mean age 42 years, compared to NZ Europeans, mean age 49 years. The average BMI was 37kg/m2 for Maori, 32 for Europeans (range 21-63, SD 8); there was a moderate relationship between clozapine use and increasing BMI (correlation coefficient of 0.74). For the diabetes patients, glycaemic control was overall suboptimal with a mean Hba1c of 66mmol/mol (range 41-117). CONCLUSIONS: Culturally appropriate, flexible and accessible services which integrate both the mental and physical health needs of Northland, New Zealand people with treatment-resistant schizophrenia on clozapine are required to reduce the 41% rate of dysglycaemia in this predominantly Maori group.

Immune Checkpoint Inhibitor Associated Hepatotoxicity in Primary Liver Cancer Versus Other Cancers: A Systematic Review and Meta-Analysis.

BACKGROUND: Overall risks of hepatotoxicity with immune checkpoint inhibitors (ICIs) have yet to be compared in primary liver cancers to other solid tumors. METHODS: We reviewed data from the PubMed, Embase, and Scopus databases, and assessed the risk of hepatotoxicity associated with ICIs. RESULTS: A total of 117 trials were eligible for the meta-analysis, including 7 trials with primary liver cancers. The most common hepatotoxicity was ALT elevation (incidence of all grade 5.29%, 95% CI 4.52-6.20) and AST elevation (incidence of all grade 5.88%, 95% CI 4.96-6.97). The incidence of all grade ALT and AST elevation was 6.01% and 6.84% for anti-PD-1 (95% CI 5.04-7.18/5.69-8.25) and 3.60% and 3.72% for anti-PD-L1 (95% CI 2.72-4.76/2.82-4.94; p< 0.001/p<0.001). The incidence of ≥ grade 3 ALT and AST elevation was 1.54% and 1.48% for anti-PD-1 (95% CI 1.19-1.58/1.07-2.04) and 1.03% and 1.08% for anti-PD-L1 (95% CI 0.71-1.51/0.80-1.45; p= 0.002/p<0.001). The incidence of all grade ALT and AST elevation was 13.3% and 14.2% in primary liver cancers (95% CI 11.1-16.0 and 9.93-20.36) vs. 4.92% and 5.38% in other solid tumors (95% CI 4.21-5.76 and 4.52-5.76 in other solid tumors; p <0.001/p<0.001). CONCLUSION: Our study indicates that anti-PD-1 is associated with a higher risk of all- and high-grade hepatotoxicity compared to anti-PD-L1, and primary liver cancers are associated with a higher risk of all- and high-grade hepatotoxicity compared to other solid tumors.

Using the Internet to recruit patients for epilepsy trials: results of a New Zealand pilot study.

PURPOSE: We created a database that could be accessed via the Internet by any neurologist or pediatric neurologist in New Zealand. The database was designed to facilitate recruitment of patients for investigator-driven drug trials. METHODS: We established an epilepsy database, and invited neurologists and pediatric neurologists throughout New Zealand to register patients via the Internet when they were uncertain of the optimal management. Details regarding seizure type and frequency, epilepsy syndrome, etiology, drug history, and investigations were collected. We produced an algorithm to select patients who had failed to respond to a single antiepileptic drug (AED). These patients were randomized immediately via the Internet to receive a different drug. Participants were not reimbursed. RESULTS: The pilot study recruited patients from mid-June to December 2007. Sixteen neurologists participated; neurologists were based in eight different cities. One hundred thirty-seven patients were registered, of whom 113 were considered suitable for drug trials. Thirty-five patients who had used a single antiepileptic drug AED were enrolled, and 14 of these were successfully randomized online to a different drug. Follow-up information was entered via the Internet for all 108 patients who were seen again during the following year. DISCUSSION: We have demonstrated that patients can be recruited for trials and randomized from routine clinics via the Internet. Trials could compare AEDs or look at other aspects of epilepsy management. An international pilot study is planned. Neurologists are invited to enroll patients with epilepsy, who would be suitable for randomized controlled trials, into a Web-based register.

Systemic treatment options for advanced biliary tract carcinoma.

Advanced biliary tract cancers (BTC) include a diverse collection of rare and heterogenous tumors with poor prognosis. The combination of gemcitabine and cisplatin is the established first-line therapy for advanced BTC. There are no accepted standard treatments in the second line setting, though there are several ongoing clinical trials that implement chemotherapy as a therapeutic strategy. The understanding of the molecular landscape of BTC has offered hope of targeted therapies to the identified actionable genomic aberrations, such as FGFR2 gene fusions, mutations of IDH1/2, HER2, BRAC1/2 and BRAF. Pembigatinib has become the first approved targeted therapy for BTC with FGFR2 fusion or other rearrangements. Recent immunotherapy has opened new therapy avenues in BTC with pembrolizumab approved for either microsatellite instability high (MSI-H) or DNA mismatch repair deficient (dMMR) advanced solid tumors, including BTC. The combination of immunotherapy with other modalities is currently being evaluated in different clinical trials, since single agent immunotherapy appears to provide modest benefits in advanced BTC. In this review, we summarize the current status of treatment options, including systemic chemotherapy, targeted therapy, immunotherapy, and various combinations in advanced BTC.

Targeting cancer stem cells in cholangiocarcinoma (Review).

The incidence of cholangiocarcinoma has been increasing steadily over the past 50 years, but the survival rates remained low due to the disease being highly resistant to non­surgical treatment interventions. Cancer stem cell markers are expressed in cholangiocarcinoma, suggesting that they serve a significant role in the physiology of the disease. Cancer stem cells are frequently implicated in tumor relapse and acquired resistance to a number of therapeutic strategies, including chemotherapy, radiation and immune checkpoint inhibitors. Novel targeted therapies to eradicate cancer stem cells may assist in overcoming treatment resistance in cholangiocarcinoma and reduce the rates of relapse and recurrence. Several signaling pathways have been previously documented to regulate the development and survival of cancer stem cells, including Notch, janus kinase/STAT, Hippo/yes­associated protein 1 (YAP1), Wnt and Hedgehog signaling. Although pharmacological agents have been developed to target these pathways, only modest effects were reported in clinical trials. The Hippo/YAP1 signaling pathway has come to the forefront in the field of cancer stem cell research due to its reported involvement in epithelium­mesenchymal transition, cell adhesion, organogenesis and tumorigenesis. In the present article, recent findings in terms of cancer stem cell research in cholangiocarcinoma were reviewed, where the potential therapeutic targeting of cancer stem cells in this disease was discussed.

Immunotherapy of hepatocellular carcinoma with infection of hepatitis B or C virus.

Hepatocellular carcinoma (HCC) has one of highest mortalities globally amongst cancers, but has limited therapeutic options once in the advanced stage. Hepatitis B or C virus infection are the most common drivers for HCC carcinogenesis, triggering chronic liver inflammation and adding to the complexity of the immune microecosystem of HCC. The emergence of immunotherapy has afforded a new avenue of therapeutic options for patients with advanced HCC with a history of hepatitis B or C virus infection. This article reviews the change of immunity elicited by hepatitis B or C virus infection, the immune feature of HCC, and the clinical evidence for immunotherapy in advanced HCC and discusses future directions in this field.

Quantum dots as fluorescence resonance energy transfer donors in cells.

Quantum dots (QDs) promise to revolutionize the way fluorescence imaging is used in the cell biology field. The unique fluorescent spectral characteristics, high photostability, low photobleaching, and tight emission spectra of QDs position them above traditional dyes. We will address the ability of water-stabilized QDs to behave as effective fluorescence resonance energy transfer (FRET) donors in cells upon transferrin-receptor-(TFR) mediated endocytosis. Confocal microscopy detects whether donor QD transferrin conjugates transfer energy to acceptor organic fluorophore-transferrin conjugate molecules in endocytic compartments. QDs are shown to be effective FRET donors when internalized into cells via the transferring receptor-mediated endocytic pathway. Upon pairing with the appropriate acceptor dyes, QDs will reduce the laborious data processing that is required to compensate for bleed through contamination between organic dye donor and acceptor pair signals. The QD technology simplifies and expands the use of FRET in the analysis of complex cellular processes that may involve protein organization in intracellular membranes as well as protein-protein interactions.

EpiNet as a way of involving more physicians and patients in epilepsy research: Validation study and accreditation process.

OBJECTIVE: EpiNet was established to encourage epilepsy research. EpiNet is used for multicenter cohort studies and investigator-led trials. Physicians must be accredited to recruit patients into trials. Here, we describe the accreditation process for the EpiNet-First trials. METHODS: Physicians with an interest in epilepsy were invited to assess 30 case scenarios to determine the following: whether patients have epilepsy; the nature of the seizures (generalized, focal); and the etiology. Information was presented in two steps for 23 cases. The EpiNet steering committee determined that 21 cases had epilepsy. The steering committee determined by consensus which responses were acceptable for each case. We chose a subset of 18 cases to accredit investigators for the EpiNet-First trials. We initially focused on 12 cases; to be accredited, investigators could not diagnose epilepsy in any case that the steering committee determined did not have epilepsy. If investigators were not accredited after assessing 12 cases, 6 further cases were considered. When assessing the 18 cases, investigators could be accredited if they diagnosed one of six nonepilepsy patients as having possible epilepsy but could make no other false-positive errors and could make only one error regarding seizure classification. RESULTS: Between December 2013 and December 2014, 189 physicians assessed the 30 cases. Agreement with the steering committee regarding the diagnosis at step 1 ranged from 47% to 100%, and improved when information regarding tests was provided at step 2. One hundred five of the 189 physicians (55%) were accredited for the EpiNet-First trials. The kappa value for diagnosis of epilepsy across all 30 cases for accredited physicians was 0.70. SIGNIFICANCE: We have established criteria for accrediting physicians using EpiNet. New investigators can be accredited by assessing 18 case scenarios. We encourage physicians with an interest in epilepsy to become EpiNet-accredited and to participate in these investigator-led clinical trials.

Gastric bypass for insulin resistance due to lipodystrophy.

We report a 41-year-old woman with severe insulin resistance due to partial lipodystrophy, who was successfully treated with gastric bypass surgery.

Screening, prevalence and ethnic variation of diabetes mellitus in people with acute stroke and transient ischaemic attack: a cross-sectional study in Northland, New Zealand.

AIM: To assess our prevalence and screening rate for diabetes and pre-diabetes in people presenting with acute stroke and transient ischaemic attack (TIA) in Northland, New Zealand, as well as identifying discrepancies between Māori and non-Māori, rates of atrial fibrillation (AF) and effect of metformin on stroke. METHOD: Data was collected retrospectively on people diagnosed with stroke or TIA in Northland, between 1 January 2014 and 31 December 2014. RESULTS: 345 people presented with acute stroke/TIA. 49.5% had dysglycaemia: 24.3% diabetes, 25.2% pre-diabetes. An HbA1c was performed on 70.4%. Māori had more diabetes (41.6%) than non-Māori (19.4%), with an HbA1c 12 mmol/mol (3.2%) higher, and were 12 years younger on average. There was no difference in AF prevalence between people with and without diabetes, and in the proportion of severe stroke (total anterior circulation infarction) between people with diabetes on metformin and those not. CONCLUSIONS: The prevalence of dysglycaemia in acute stroke/TIA in Northland is high. The goal of universal HbA1c screening in stroke is not being met. Māori have stroke younger, and a higher prevalence of diabetes may partially explain this. No association between diabetes and AF was found, nor evidence that metformin may be protective against larger strokes.