Robotic Lobectomy Is Cost-effective and Provides Comparable Health Utility Scores to Video-assisted Lobectomy: Early Results of the RAVAL Trial.

OBJECTIVE: The aim of this study was to determine if robotic-assisted lobectomy (RPL-4) is cost-effective and offers improved patient-reported health utility for patients with early-stage non-small cell lung cancer when compared with video-assisted thoracic surgery lobectomy (VATS-lobectomy). BACKGROUND: Barriers against the adoption of RPL-4 in publicly funded health care include the paucity of high-quality prospective trials and the perceived high cost of robotic surgery. METHODS: Patients were enrolled in a blinded, multicentered, randomized controlled trial in Canada, the United States, and France, and were randomized 1:1 to either RPL-4 or VATS-lobectomy. EuroQol 5 Dimension 5 Level (EQ-5D-5L) was administered at baseline and postoperative day 1; weeks 3, 7, 12; and months 6 and 12. Direct and indirect costs were tracked using standard methods. Seemingly Unrelated Regression was applied to estimate the cost effect, adjusting for baseline health utility. The incremental cost-effectiveness ratio was generated by 10,000 bootstrap samples with multivariate imputation by chained equations. RESULTS: Of 406 patients screened, 186 were randomized, and 164 analyzed after the final eligibility review (RPL-4: n=81; VATS-lobectomy: n=83). Twelve-month follow-up was completed by 94.51% (155/164) of participants. The median age was 68 (60-74). There were no significant differences in body mass index, comorbidity, pulmonary function, smoking status, baseline health utility, or tumor characteristics between arms. The mean 12-week health utility score was 0.85 (0.10) for RPL-4 and 0.80 (0.19) for VATS-lobectomy ( P =0.02). Significantly more lymph nodes were sampled [10 (8-13) vs 8 (5-10); P =0.003] in the RPL-4 arm. The incremental cost/quality-adjusted life year of RPL-4 was $14,925.62 (95% CI: $6843.69, $23,007.56) at 12 months. CONCLUSION: Early results of the RAVAL trial suggest that RPL-4 is cost-effective and associated with comparable short-term patient-reported health utility scores when compared with VATS-lobectomy.

Preconditioning program reduces the incidence of prolonged hospital stay after lung cancer surgery: Results from the Move For Surgery randomized clinical trial.

BACKGROUND: Lung cancer resection is associated with high rates of prolonged hospital stay. It is presumed that preconditioning with aerobic exercise can shorten the postoperative duration of hospital stay, but this has not yet been demonstrated in trials after lung cancer surgery. The aim of this study was to perform a RCT to determine whether Move For Surgery (MFS), a home-based and wearable technology-enhanced preconditioning program before lung cancer surgery, is associated with a lower incidence of prolonged hospital stay when compared to usual preoperative care. METHODS: Patients undergoing lung resection for early-stage non-small cell lung cancer were enrolled before surgery into this blinded, single-site RCT, and randomized to either the MFS or control group in a 1 : 1 ratio. Patients in the MFS group were given a wearable activity tracker, and education about deep breathing exercises, nutrition, sleep hygiene, and smoking cessation. Participants were motivated/encouraged to reach incrementally increasing fitness goals remotely. Patients in the control group received usual preoperative care. The primary outcome was the difference in proportion of patients with hospital stay lasting more than 5 days between the MFS and control groups. RESULTS: Of 117 patients screened, 102 (87.2 per cent) were eligible, enrolled, and randomized (51 per trial arm). The majority (95 of 102, 93.1 per cent) completed the trial. Mean(s.d.) age was 67.2(8.8) years and there were 55 women (58 per cent). Type of surgery and rates of thoracotomy were not different between arms. The proportion of patients with duration of hospital stay over 5 days was 3 of 45 (7 per cent) in the MFS arm compared to 12 of 50 (24 per cent) in the control arm (P = 0.021). CONCLUSION: MFS, a home-based and wearable technology-enhanced preconditioning program before lung cancer surgery, decreased the proportion of patients with a prolonged hospital stay. Registration number: NCT03689634 (http://www.clinicaltrials.gov).

After lung cancer surgery, many patients are admitted to hospital for a prolonged amount of time. It is believed that exercises undertaken before surgery can shorten the stay in hospital, but this has not yet been studied. This study aimed to find out whether Move For Surgery (MFS), a home-based exercise (preconditioning) program using wearable technology before lung cancer surgery, can decrease the number of patients who are admitted to hospital for a prolonged amount of time. Patients with lung cancer were invited to enter this trial 3­4 weeks before surgery. They were randomly put into the MFS or control group. Patients in the MFS group were given a wearable activity tracker, and education about deep breathing exercises, nutrition, sleep hygiene, and quitting smoking. Participants were encouraged to reach increasing fitness goals each week. Patients in the control group underwent usual preoperative care. The difference between the MFS and control groups in the proportion of patients with duration of stay in hospital exceeding 5 days was studied. There were 102 participants in total, 51 in each group. The majority (95 of 102, 93.1 per cent) completed the trial. The average age of participants was 67 years, and 58 per cent were women. Type of surgery and number of open operations were no different between groups. The proportion of patients with duration of stay greater than 5 days was 3 of 45 (7 per cent) in the MFS group compared with 12 of 50 (24 per cent) in the control group. Therefore, MFS before lung cancer surgery was shown to decrease the number of patients admitted to hospital for a prolonged amount of time.

Robotic thoracic surgery in Canada: Are patients willing to pay out of pocket?

Robotic-assisted thoracoscopic surgery (RTS) is safe and effective, but is associated with high capital and operating costs that are not reimbursed by the Canadian government. Currently, patients have access to RTS only when it is supported by research or philanthropic funds. In a recent study, we assessed the extent of patient-reported satisfaction with RTS, whether patients would have been willing to pay out of pocket for it, and what factors were associated with patients' willingness to pay. Many patients (290 of 411 [70.56%]) stated that they would have paid the additional $2000 to supplement the government health care coverage to have access to RTS. Factors found to be significantly associated with participants' willingness to pay were an annual income of $60 000 or more (p = 0.034), private insurance coverage (p = 0.007), overall experience with RTS rated as 8 or higher out of 10 (p < 0.001), and overall postoperative postdischarge experience rated as satisfying or very satisfying (p = 0.004).

Long-term durability and safety of fecal microbiota transplantation for recurrent or refractory Clostridioides difficile infection with or without antibiotic exposure.

Fecal microbiota transplant (FMT) is a safe and effective treatment for recurrent or refractory Clostridioides (Clostridium) difficile infection (RCDI) in the short term. However, there are a paucity of data on long-term durability and safety of FMT. The aim of this study is to determine the long-term efficacy and safety of FMT for RCDI. Ninety-four patients underwent FMT via retention enema for RCDI between 2008 and 2012 and completed a follow-up questionnaire 4 to 8 years following the last FMT. Of these, 32 were unreachable and 37 were deceased; 23 of the remaining 25 participants completed the survey. No CDI recurrences were reported in patients treated with FMT; 12 of the 23 participants (52.2%) received at least one course of non-CDI antibiotic(s). Nine participants (40.9%) received probiotics and 4 (17.4%) received both non-CDI antibiotics and probiotics. All 23 participants rated their overall health compared with pre-FMT. Current health was considered "much better" in 17 patients (73.9%); "somewhat better" in 3 patients (13.0%); and "about the same" in 3 patients (13.0%). A total of 11 participants (47.8%) reported an increase in weight of more than 5 kg (kg) post-FMT and 9 participants (39.1%) reported no change in weight (± 5 kg). Four of the 23 participants (17.4%) reported improvement or resolution (undifferentiated colitis, n = 1; Crohn's disease, n = 2; ulcerative colitis, n = 1) of pre-existing gastrointestinal condition following FMT. Eight of 23 participants (34.8%) experienced new medical condition(s) post-FMT. The long-term efficacy (48-96 months) of FMT for RCDI appears to be durable even after non-CDI antibiotic use. Thirty percent had improvement of their pre-existing medical conditions following FMT; 73.9% reported "much better" overall health following FMT.

The DNAJA2 substrate release mechanism is essential for chaperone-mediated folding.

DNAJA1 (DJA1/Hdj2) and DNAJA2 (DJA2) are the major J domain partners of human Hsp70/Hsc70 chaperones. Although they have overall similarity with the well characterized type I co-chaperones from yeast and bacteria, they are biologically distinct, and their functional mechanisms are poorly characterized. We identified DJA2-specific activities in luciferase folding and repression of human ether-a-go-go-related gene (HERG) trafficking that depended on its expression levels in cells. Mutations in different internal domains of DJA2 abolished these effects. Using purified proteins, we addressed the mechanistic defects. A mutant lacking the region between the zinc finger motifs (DJA2-Δm2) was able to bind substrate similar to wild type but was incapable of releasing substrate during its transfer to Hsc70. The equivalent mutation in DJA1 also abolished its substrate release. A DJA2 mutant (DJA-221), which had its C-terminal dimerization region replaced by that of DJA1, was inactive but retained its ability to release substrate. The release mechanism required the J domain and ATP hydrolysis by Hsc70, although the nucleotide dependence diverged between DJA2 and DJA1. Limited proteolysis suggested further conformational differences between the two wild-type co-chaperones and the mutants. Our results demonstrate an essential role of specific DJA domains in the folding mechanism of Hsc70.

Preoperative mediastinal staging in early-stage lung cancer: Targeted nodal sampling is not inferior to systematic nodal sampling.

OBJECTIVE: To determine whether targeted sampling (TS), which omits biopsy of triple- normal lymph nodes (LNs) on positron emission tomography, computed tomography, and endobronchial ultrasound (EBUS), is noninferior to systematic sampling (SS) of mediastinal LNs during EBUS for staging of patients with early-stage non-small cell lung cancer (NSCLC). METHODS: Patients who are clinical nodal (cN)0-N1 with suspected NSCLC eligible for EBUS based on positron emission tomography/computed tomography were enrolled in this prospective, multicenter trial. During EBUS, all patients underwent TS and then crossed over to SS, whereby at least 3 mediastinal LN stations (4R, 4L, 7) were routinely sampled. Gold standard of comparison was pathologic results. Based on the previous feasibility trial, a noninferiority margin of 6% was established for difference in missed nodal metastasis (MNM) incidence between TS and SS. The McNemar test on paired proportions was used to determine MNM incidence for each sampling method. Analysis was per-protocol using a level of significance of P < .05. RESULTS: Between November 2020 and April 2022, 91 patients were enrolled at 6 high-volume Canadian tertiary care centers. A total of 256 LNs underwent TS and SS. Incidence of MNM was 0.78% in SS and 2.34% in TS, with an absolute difference of 1.56% (95% confidence interval, -0.003% to 4.1%; P = .13). This falls within the noninferiority margin. A total of 6/256 LNs from 4 patients who were not sampled by TS were found to be malignant when sampled by SS. CONCLUSIONS: In high-volume thoracic endosonography centers, TS is not inferior to SS in nodal staging of early-stage NSCLC. This results in change of clinical management for a minority of patients.

Systems-level analyses of protein-protein interaction network dysfunctions via epichaperomics identify cancer-specific mechanisms of stress adaptation.

Systems-level assessments of protein-protein interaction (PPI) network dysfunctions are currently out-of-reach because approaches enabling proteome-wide identification, analysis, and modulation of context-specific PPI changes in native (unengineered) cells and tissues are lacking. Herein, we take advantage of chemical binders of maladaptive scaffolding structures termed epichaperomes and develop an epichaperome-based 'omics platform, epichaperomics, to identify PPI alterations in disease. We provide multiple lines of evidence, at both biochemical and functional levels, demonstrating the importance of these probes to identify and study PPI network dysfunctions and provide mechanistically and therapeutically relevant proteome-wide insights. As proof-of-principle, we derive systems-level insight into PPI dysfunctions of cancer cells which enabled the discovery of a context-dependent mechanism by which cancer cells enhance the fitness of mitotic protein networks. Importantly, our systems levels analyses support the use of epichaperome chemical binders as therapeutic strategies aimed at normalizing PPI networks.

Use of the V-sign in the diagnosis of bucket-handle meniscal tear of the knee.

OBJECTIVE: Bucket-handle tear is a displaced vertical longitudinal tear of the meniscus. Several signs of the tear have been described on MRI but none in the axial plane. We propose to describe such a sign named the V-sign that is seen at the junction of the displaced fragment and the meniscus, which is in place. MATERIALS AND METHODS: MRI imaging of 25 surgically proven bucket-handle tears was reviewed for presence of the V-sign. Two control groups, one with normal menisci (n = 75) and one with surgically proven non-bucket-handle tears (n = 25), were also evaluated. Comparisons for presence or absence of the V-sign were performed among the three groups, and also for other commonly associated signs such as double PCL sign, double delta sign, and presence of ACL tear. Also, sensitivity, specificity, and positive and negative predictive values were calculated. RESULTS: Among those with bucket-handle tear, 72% demonstrated the V-sign while no participant in either control group had the V-sign (P ≤ 0.001). The V-sign occurred in 38% of those with double PCL sign, 55.6% with ACL tear, and 66.7% with double delta sign. The V-sign had higher sensitivity and negative predictive values than other signs related to bucket-handle tear. CONCLUSION: The V-sign, when seen on an axial plane image, is highly suggestive of bucket-handle tear. Our data suggest the benefit of using the V-sign for detecting bucket-handle tears, perhaps even above other commonly used approaches.

An Artificial Intelligence Algorithm to Predict Nodal Metastasis in Lung Cancer.

BACKGROUND: Endobronchial ultrasound (EBUS) has features that allow a high accuracy for predicting lymph node (LN) malignancy. However their clinical application remains limited because of high operator dependency. We hypothesized that an artificial intelligence algorithm (NeuralSeg; NeuralSeg Ltd, Hamilton, Ontario, Canada) is capable of accurately identifying and predicting LN malignancy based on EBUS images. METHODS: In the derivation phase EBUS images were segmented twice by an endosonographer and used as controls in 5-fold cross-validation training of NeuralSeg. In the validation phase the algorithm was tested on new images it had not seen before. Logistic regression and receiver operator characteristic curves were used to determine NeuralSeg's capability of discrimination between benign and malignant LNs, using pathologic specimens as the gold standard. RESULTS: Two hundred ninety-eight LNs from 140 patients were used for derivation and 108 LNs from 47 patients for validation. In the derivation cohort NeuralSeg was able to predict malignant LNs with an accuracy of 73.8% (95% confidence interval [CI], 68.4%-78.7%). In the validation cohort NeuralSeg had an accuracy of 72.9% (95% CI, 63.5%-81.0%), specificity of 90.8% (95% CI, 81.9%-96.2%), and negative predictive value of 75.9% (95% CI, 71.5%-79.9%). NeuralSeg showed higher diagnostic discrimination during validation compared with derivation (c-statistic = 0.75 [95% CI, 0.65-0.85] vs 0.63 [95% CI, 0.54-0.72], respectively). CONCLUSIONS: NeuralSeg is able to accurately rule out nodal metastasis and can possibly be used as an adjunct to EBUS when nodal biopsy is not possible or inconclusive. Future work to evaluate the algorithm in a clinical trial is required.

Routine systematic sampling versus targeted sampling during endobronchial ultrasound: A randomized feasibility trial.

OBJECTIVE: Triple normal lymph nodes, appearing benign on computed tomography, positron emission tomography, and endobronchial ultrasound, have less than a 6% probability of malignancy. We hypothesized that targeted sampling (TS), which omits biopsy of triple normal lymph nodes during endobronchial ultrasound, is not an inferior staging strategy to systematic sampling (SS) of all lymph nodes. METHODS: A prospective randomized feasibility trial was conducted to decide on the progression to a pan-Canadian trial comparing TS with SS. Patients with cN0-N1 non-small cell lung cancer undergoing endobronchial ultrasound were randomized to TS or SS. Lymph nodes in the TS arm crossed over to receive SS. Progression criteria included recruitment rate (70% minimum), procedure length (no significant increase for TS), and incidence of missed nodal metastasis (<6%). Mann-Whitney U test and McNemar's test on paired proportions were used for statistical comparisons. RESULTS: The progression criterion of 70% recruitment rate was achieved early, triggering a planned early stoppage of the trial. Nineteen patients were allocated to each arm. The median procedure length for TS was significantly shorter than SS (3.07 vs 19.07 minutes; P < .001). After crossover analysis, 5.45% (95% confidence interval, 1.87-14.85) of lymph nodes in the TS arm were upstaged from N0 to N2, but this incidence of missed nodal metastasis was below the 6% threshold. During surgical resection, the nodal upstaging incidence from N0 to N2 was 0% for 15 lymph nodes in each arm. CONCLUSIONS: Progression criteria to a pan-Canadian, noninferiority crossover trial comparing TS with SS have been met, and such a trial is warranted.

Robotic vs Thoracoscopic Anatomic Lung Resection in Obese Patients: A Propensity-Adjusted Analysis.

BACKGROUND: Minimally invasive lung resections can be particularly challenging in obese patients. We hypothesized robotic surgery (RTS) is associated with less conversion to thoracotomy than video-assisted thoracoscopic surgery (VATS) in obese populations. METHODS: The Society of Thoracic Surgeons General Thoracic Surgery Database, Epithor French National Database, and McMaster University Thoracic Surgical Database were queried for obese (body mass index ≥30 kg/m2) patients who underwent VATS or RTS lobectomy or segmentectomy for clinical T1-2, N0-1 non-small cell lung cancer between 2015 and 2019. Propensity score adjusted logistic regression analysis was used to compare the rate of conversion to thoracotomy between the VATS and RTS cohorts. RESULTS: Overall, 8108 patients (The Society of Thoracic Surgeons General Thoracic Surgery Database: n = 7473; Epithor: n = 572; McMaster: n = 63) met inclusion criteria with a mean (SD) age of 66.6 (9) years and body mass index of 34.7 (4.5) kg/m2. After propensity score adjusted multivariable analysis, patients who underwent VATS were >5-times more likely to experience conversion to thoracotomy than those who underwent RTS (odds ratio, 5.33; 95% CI, 4.14-6.81; P < .001). There was a linear association between the degree of obesity and odds ratio of VATS conversion to thoracotomy compared with RTS. VATS patients had a longer mean length of stay (5.0 vs 4.3 days, P < .001), higher rate of respiratory failure (2.8% [168 of 5975] vs 1.8% [39 of 2133], P = .026), and were less likely to be discharged to their home (92.5% [5525 of 5975] vs 94.3% [2012 of 2133]; P = .013) compared with RTS patients. CONCLUSIONS: In obese patients, RTS anatomic lung resection is associated with a lower rate of conversion to thoracotomy than VATS.

RAVAL trial: Protocol of an international, multi-centered, blinded, randomized controlled trial comparing robotic-assisted versus video-assisted lobectomy for early-stage lung cancer.

BACKGROUND: Retrospective data demonstrates that robotic-assisted thoracoscopic surgery provides many benefits, such as decreased postoperative pain, lower mortality, shorter length of stay, shorter chest tube duration, and reductions in the incidence of common postoperative pulmonary complications, when compared to video-assisted thoracoscopic surgery. Despite the potential benefits of robotic surgery, there are two major barriers against its widespread adoption in thoracic surgery: lack of high-quality prospective data, and the perceived higher cost of it. Therefore, in the face of these barriers, a prospective randomized controlled trial comparing robotic- to video-assisted thoracoscopic surgery is needed. The RAVAL trial is a two-phase, international, multi-centered, blinded, parallel, randomized controlled trial that is comparing robotic- to video-assisted lobectomy for early-stage non-small cell lung cancer that has been enrolling patients since 2016. METHODS: The RAVAL trial will be conducted in two phases: Phase A will enroll 186 early-stage non-small cell lung cancer patients who are candidates for minimally invasive pulmonary lobectomy; while Phase B will continue to recruit until 592 patients are enrolled. After consent, participants will be randomized in a 1:1 ratio to either robotic- or video-assisted lobectomy, and blinded to the type of surgery they are allocated to. Health-related quality of life questionnaires will be administered at baseline, postoperative day 1, weeks 3, 7, 12, months 6, 12, 18, 24, and years 3, 4, 5. The primary objective of the RAVAL trial is to determine the difference in patient-reported health-related quality of life outcomes between the robotic- and video-assisted lobectomy groups at 12 weeks. Secondary objectives include determining the differences in cost-effectiveness, and in the 5-year survival data between the two arms. The results of the primary objective will be reported once Phase A has completed accrual and the 12-month follow-ups are completed. The results of the secondary objectives will be reported once Phase B has completed accrual and the 5-year follow-ups are completed. DISCUSSION: If successfully completed, the RAVAL Trial will have studied patient-reported outcomes, cost-effectiveness, and survival of robotic- versus video-assisted lobectomy in a prospective, randomized, blinded fashion in an international setting. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02617186. Registered 22-September-2015. https://clinicaltrials.gov/ct2/show/NCT02617186.

Twitter Activity Is Associated With a Higher Research Citation Index for Academic Thoracic Surgeons.

BACKGROUND: Academic surgeons are encouraged to promote their work on social media. We hypothesized that thoracic surgeons who are active on Twitter have a higher research citation index (Hirsch index [h-index]) than their counterparts who are not. METHODS: Thoracic surgeons on CTSNet.org in Canada and the United States were queried for profiles with an h-index on Google Scholar and/or Research Gate in July 2018. Surgeons were categorized by whether they possessed a Twitter account (T+) or not (T-), and h-index values were compared. Within the T+ cohort a multivariate regression model was used to identify independent predictors of increased h-index among variables related to Twitter activity. RESULTS: Of 3741 surgeons queried, 19.3% (722) had a known h-index. The mean h-index for the entire cohort was 14.54 (SD, 15.73). The median h-index was 10 (range, 0-121), and the 75th percentile h-index was 20. T+ surgeons had a median h-index of 10 (range, 0-66), and T- surgeons had a median h-index of 10 (range, 0-72; P = .25). The 75th percentile h-index for T+ surgeons was 23 compared with 20 for T- surgeons (P = .24). For T+ surgeons the regression model identified the number of followers (P = .029), the number of people followed (P = .048), and the frequency of tweeting (P = .046) as independent predictors of a higher h-index. CONCLUSIONS: The median h-index for an academic thoracic surgeon in Canada and the United States is 10. Surgeons who engage in Twitter activity are more likely to have their research cited by others.

Near-infrared mapping with indocyanine green is associated with an increase in oncological margin length in minimally invasive segmentectomy.

BACKGROUND: Near-infrared fluorescence mapping with indocyanine green dye is a recent advancement in minimally invasive segmental resection. This technique has not yet been reproduced, validated, or objectively evaluated in a large prospective case series. We hypothesized that near-infrared fluorescence mapping is associated with an increased oncological margin distance from the tumor, over and above the best judgment of the surgeon. METHODS: This was a phase 2 prospective cohort trial in patients who are undergoing robotic segmentectomy for lung tumors <3 cm. The predicted intersegmental plane was first identified by consensus between 2 thoracic surgeons. The true plane was then mapped by indocyanine green injection. A 7-item binary rating scale was used for the evaluation of feasibility, reproducibility, and added oncological margin distance from the tumor. The margin distance between the tumor and the true plane was compared with the margin distance between the tumor and the predicted plane. RESULTS: Fifty-three patients were enrolled between September 2016 and May 2018 and 31 patients (58.4%) received the planned operation with indocyanine green mapping. In 74.2% of cases (23 out of 31), a score of 7 out of 7 was achieved, indicating the true intersegmental plane identified by indocyanine green mapping was different than the predicted plane identified by the surgeon. In 61.2% (19 out of 31) of those cases, the mean additional margin distance from the tumor to the staple line attributable to the indocyanine green mapping was 2.41 ± 1.6 cm. The overall complication rate was 18.5% (10 out of 53) and there were no deaths. CONCLUSIONS: Near-infrared fluorescence mapping in robotic segmentectomy is associated with increased oncological margin length, over and above the best judgment of the surgeon, in the majority cases where it is used.

Acceptability of the Fitbit in behavioural activation therapy for depression: a qualitative study.

INTRODUCTION: Major depressive disorder is characterised by low mood and poor motivation. Literature suggests that increased physical activity has positive effects on alleviating depression. Fitness-tracking devices may complement behavioural activation (BA) therapy to improve physical activity and mental health in patients with depression. OBJECTIVES: To understand patients' perceived benefit from the Fitbit and explore themes associated with patient experiences. To compare perceived benefit, patient factors, Fitbit usage and Beck's Depression Inventory (BDI) scores. METHODS: Semistructured interviews were conducted with patients (n=36) who completed a 28-week BA group programme in a mood disorders outpatient clinic. All patients were asked to carry a Fitbit One device. We conducted thematic analyses on the interviews and exploratory quantitative analyses on patient characteristics, Fitbit usage, steps recorded, perceived benefit and BDI scores. FINDINGS: Twenty-three patients found the Fitbit helpful for their physical activity. Themes of positive experiences included self-awareness, peer motivation and goal-setting opportunities. Negative themes included inconvenience, inaccuracies and disinterest. Age, baseline and change in BDI scores, prior physical activity goals and familiarity with technology were not associated with perceived benefit from the Fitbit or usage. Perceived benefit was significantly (p<0.01) associated with usage. CONCLUSIONS: Overall, the Fitbit is an acceptable tool to complement BA therapy for patients with depression. Many positive themes were concordant with current literature; however, patients also reported negative aspects that may affect use. CLINICAL IMPLICATIONS: Clinicians and researchers should consider both strengths and limitations of activity trackers when implementing them to motivate patients with depression. TRIAL REGISTRATION NUMBER: NCT02045771; Pre-results.

Development and Validation of Stability-indicating HPLC Method for Simultaneous Estimation of Cefixime and Linezolid.

A stability-indicating reverse phase high performance liquid chromatography method was developed and validated for cefixime and linezolid. The wavelength selected for quantitation was 276 nm. The method has been validated for linearity, accuracy, precision, robustness, limit of detection and limit of quantitation. Linearity was observed in the concentration range of 2-12 µg/ml for cefixime and 6-36 µg/ml for linezolid. For RP-HPLC, the separation was achieved by Phenomenex Luna C18 (250×4.6 mm) 5 µm column using phosphate buffer (pH 7):methanol (60:40 v/v) as mobile phase with flow rate 1 ml/min. The retention time of cefixime and linezolid were found to be 3.127 min and 11.986 min, respectively. During force degradation, drug product was exposed to hydrolysis (acid and base hydrolysis), H2O2, thermal degradation and photo degradation. The % degradation was found to be 10 to 20% for both cefixime and linezolid in the given condition. The method specifically estimates both the drugs in presence of all the degradants generated during forced degradation study. The developed methods were simple, specific and economic, which can be used for simultaneous estimation of cefixime and linezolid in tablet dosage form.

Heat shock protein 70 inhibitors. 2. 2,5'-thiodipyrimidines, 5-(phenylthio)pyrimidines, 2-(pyridin-3-ylthio)pyrimidines, and 3-(phenylthio)pyridines as reversible binders to an allosteric site on heat shock protein 70.

The discovery and development of heat shock protein 70 (Hsp70) inhibitors is currently a hot topic in cancer. In the preceding paper in this issue ( 10.1021/jm401551n ), we have described structure-activity relationship studies in the first Hsp70 inhibitor class rationally designed to bind to a novel allosteric pocket located in the N-terminal domain of the protein. These ligands contained an acrylamide to take advantage of an active cysteine embedded in the allosteric pocket and acted as covalent protein modifiers upon binding. Here, we perform chemical modifications around the irreversible inhibitor scaffold to demonstrate that covalent modification is not a requirement for activity within this class of compounds. The study identifies derivative 27c, which mimics the biological effects of the irreversible inhibitors at comparable concentrations. Collectively, the back-to-back manuscripts describe the first pharmacophores that favorably and selectively interact with a never explored pocket in Hsp70 and provide a novel blueprint for a cancer-oriented development of Hsp70-directed ligands.

Identification of an allosteric pocket on human hsp70 reveals a mode of inhibition of this therapeutically important protein.

Hsp70s are important cancer chaperones that act upstream of Hsp90 and exhibit independent anti-apoptotic activities. To develop chemical tools for the study of human Hsp70, we developed a homology model that unveils a previously unknown allosteric site located in the nucleotide binding domain of Hsp70. Combining structure-based design and phenotypic testing, we discovered a previously unknown inhibitor of this site, YK5. In cancer cells, this compound is a potent and selective binder of the cytosolic but not the organellar human Hsp70s and has biological activity partly by interfering with the formation of active oncogenic Hsp70/Hsp90/client protein complexes. YK5 is a small molecule inhibitor rationally designed to interact with an allosteric pocket of Hsp70 and represents a previously unknown chemical tool to investigate cellular mechanisms associated with Hsp70.