Alpha-emitter Peptide Receptor Radionuclide Therapy in Neuroendocrine Tumors

Peptide receptor radionuclide therapy (PRRT) has become mainstream therapy of metastatic neuroendocrine tumors not controlled by somatostatin analog therapy. Currently, beta particle-emitting radiopharmaceuticals are the mainstay of PRRT. Alpha particle-emitting radiopharmaceuticals have a theoretic advantage over beta emitters in terms of improved therapeutic efficacy due to higher cancer cell death and lower nontarget tissue radiation-induced adverse events due to shorter path length of alpha particles. We discuss the available evidence for and the role of alpha particle PRRT.

Accuracy of portable ultrasound machines for obstetric biometry

OBJECTIVE

To evaluate the accuracy of two portable ultrasound machines (PUM) in assessing fetal biometry and estimated gestational age (EGA).

METHODS

This was a secondary analysis of data from the Fetal Age Machine Learning Initiative, an observational study of pregnant women in the USA and Zambia. Each participant underwent ultrasound assessment by an experienced sonographer using both a high-specification ultrasound machine (HSUM) and a PUM (Butterfly iQ or Clarius C3) to measure fetal biometry and calculate EGA at each visit. By comparing paired PUM and HSUM scans, we estimated agreement between individual biometry measurements and aggregate gestational age estimates by reporting mean difference, intraclass correlation coefficient (ICC) and Bland-Altman plots, adjusting for trend.

RESULTS

Between April and December 2021, 818 participants contributed 1386 paired PUM-HSUM ultrasound investigations, of which 991 PUM scans were obtained using the Butterfly iQ device and 395 using the Clarius C3 device. Gestational age at scan ranged from 7 to 38 weeks. Compared with HSUM, the Butterfly iQ PUM had a mean difference of -0.20 (95% CI, -0.60 to 0.20) days in the first trimester and -0.68 (95% CI, -0.93 to -0.44) days in the second/third trimesters. Compared with HSUM, the Clarius C3 PUM had a mean difference of -0.47 (95% CI, -1.11 to 0.18) days in the first trimester and -1.67 (95% CI, -2.10 to -1.25) days in the second/third trimesters. ICCs were 0.989 or greater throughout. Increasing gestational age was associated with increasing error and absolute error in EGA and fetal biometry. Both PUM devices demonstrated a modest trend toward underestimation of EGA with advancing gestational age in second/third-trimester scans, compared with HSUM.

CONCLUSION

The Butterfly iQ and Clarius C3 PUM devices were highly accurate in performing fetal biometry in a diverse population from the USA and Zambia. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

Real-world hepatitis C prevalence and treatment uptake at opioid agonist therapy clinics in Ontario, Canada

Widespread screening for hepatitis C virus (HCV) is necessary for Canada to meet its HCV elimination goals by 2030. People who currently or previously injected drugs are at high risk for HCV. Opioid agonist therapy (OAT, such as methadone and buprenorphine) has been shown to help stabilize the lives of people who are opioid-dependent. The distribution of OAT in North America typically requires daily, weekly, or monthly clinic visits and presents an opportunity for engagement, screening and treatment for those at high-risk of HCV. In this study, HCV screening was conducted by staff at OAT clinics in Ontario from 2016 to 2020 and those with chronic infections were treated on-site with direct-acting antivirals. Point-of-care or dried blood spot (DBS) testing was used for antibodies, DBS or serum for HCV RNA and serum for HCV RNA at SVR12 (sustained virological response). Clinics screened 1954 people (mean age 40 years ±12, 63% male). Forty-five percent were antibody positive, of whom 64% were HCV RNA+. Eighty percent of those RNA+ set an appointment in which 99% attended. Ninety-six percent started treatment with 87% completing treatment. Sixty-eight percent of people who completed treatment submitted a sample for SVR12 testing of which 97% achieved a virological cure. Results suggest that HCV screening and treatment at OAT clinics is feasible, effective and warrants expansion. Data suggest strong treatment adherence due to high rates of SVR12 comparable with other OAT-based HCV treatment programs. The lack of SVR12 sampling could be addressed by either on-site phlebotomy or incentivizing SVR12 sampling.

A comprehensive patient-specific prediction model for temporomandibular joint osteoarthritis progression

Temporomandibular joint osteoarthritis (TMJ OA) is a prevalent degenerative disease characterized by chronic pain and impaired jaw function. The complexity of TMJ OA has hindered the development of prognostic tools, posing a significant challenge in timely, patient-specific management. Addressing this gap, our research employs a comprehensive, multidimensional approach to advance TMJ OA prognostication. We conducted a prospective study with 106 subjects, 74 of whom were followed up after 2 to 3 y of conservative treatment. Central to our methodology is the development of an innovative, open-source predictive modeling framework, the Ensemble via Hierarchical Predictions through Nested cross-validation tool (EHPN). This framework synergistically integrates 18 feature selection, statistical, and machine learning methods to yield an accuracy of 0.87, with an area under the ROC curve of 0.72 and an F1 score of 0.82. Our study, beyond technical advancements, emphasizes the global impact of TMJ OA, recognizing its unique demographic occurrence. We highlight key factors influencing TMJ OA progression. Using SHAP analysis, we identified personalized prognostic predictors: lower values of headache, lower back pain, restless sleep, condyle high gray level-GL-run emphasis, articular fossa GL nonuniformity, and long-run low GL emphasis; and higher values of superior joint space, mouth opening, saliva Vascular-endothelium-growth-factor, Matrix-metalloproteinase-7, serum Epithelial-neutrophil-activating-peptide, and age indicate recovery likelihood. Our multidimensional and multimodal EHPN tool enhances clinicians' decision-making, offering a transformative translational infrastructure. The EHPN model stands as a significant contribution to precision medicine, offering a paradigm shift in the management of temporomandibular disorders and potentially influencing broader applications in personalized healthcare.

Evaluation Of Development Of Clinical Reasoning Skills In Dental Students Through Diagnostic Thinking Inventory

Objective

To assessthe clinical reasoning skills among dentalstudents, and to compare the diagnostic thinking ability of male and female students.

METHODS

The cross-sectionalstudy was conducted from May to July 2021 at a public-sector dental school in Karachi, and comprised students of both genders from across allthe four years ofdentalschool.Datawas collectedusing thediagnostic thinking inventory which also assessed flexibility in thinking and knowledge structure inmemory.Datawas analysedusing SPSS 18.

RESULTS

Of the 111 forms distributed, 108(98.2%) were received duly filled; 32 (29.35%) from male students and 76(69.72) from female students. Participants from the first year were 24(22%), second year 23(21%), third year 33 (30.27%) and the fourth year 29(26.6%).The reliability of diagnostic thinking inventory was 0.906, for knowledge structure in memory 0.661, andflexibility inthinking0.573.The correlationwassignificantforstudentsintheir 2nd, 3rdand4thyearsofstudies(p=0.01) The overall mean score was <150 which was poor. Both the knowledge structure in memory, and flexibility in thinking scores were higher for females compared to males(Significant at the level of 0.01).

Conclusion

The clinical reasoning skills of students were low, and the diagnostic thinking ability of female students was better than that of their male counterparts.

Imaging characteristics of idiopathic scleroma: a retrospective case series and review of the literature

BACKGROUND

Idiopathic scleroma (previously coined solitary idiopathic choroiditis or focal scleral nodule) is an innocuous lesion affecting the sclera with intraocular manifestations. It is often the basis of many misdiagnoses such as amelanotic choroidal melanoma, osteoma or metastatic lesions. Patients are often asymptomatic and the course is benign. With increasing use of community based imaging, more of such cases are being identified. This paper is a retrospective case series investigating the multi-modal imaging findings of idiopathic scleroma.

METHODS

A retrospective analysis of prospectively collected data were analysed. Over the course of January 2008-January 2022, 44 patients diagnosed with idiopathic scleroma and imaged with wide-field colour fundus photography, fundus autofluorescence, ocular coherence tomography (OCT) and B-scan ultrasonography. Due to a poor image, only 43 images were included for OCT review. We also reviewed our patient's demographics, symptoms and baseline ophthalmic characteristics upon presentation.

RESULTS

The mean age was 52 years (range 32-79) and there was no predilection towards gender. All lesions were post equatorial with the most common location being inferotemporal (n = 16, 36%); 32 lesions (73%) were yellow on fundus photography. 82% (n = 36/44) of lesions exhibited hyperautoflourescence and 43 lesions (98%) showed hyperechogenicity on B-scan ultrasonography. 100% of lesions originated from the sclera with no lesions showing active inflammation. 20 (47%) lesions had associated blood vessels overlying them on OCT.

DISCUSSION

Idiopathic scleroma is a yellow, hyperautofluorescent, hyperechogeneic scleral lesion that has no signs of active inflammation. These characteristics help define them from other more sinister cause of amelanotic fundal lesions.

Cross Infection Control Awareness During 5th Wave of Covid 19 Pandemic, Omicron Variant Amongst the Dental Health Care Professionals of Government Sector University in Karachi, Pakistan

Objective: The objective of this study is to evaluate the awareness of cross-infection control measures followed by DHCPs during the 5th wave of Covid-19 pandemic, Omicron variant in a government sector university of Karachi, Pakistan. Method: A Cross-sectional study was conducted from June till September 2022 at Sindh Institute of Oral Health Science during the 5th wave of Covid 19 pandemic, Omicron variant. Data was collected from 153 DHCPs from government sector university using a self-administered questionnaire, comprising of 20 closed ended question to assess the awareness and practice of cross infection protocols by DHCPs. Results: 98.7% of the participants were vaccinated against Covid 19. 96% of the participants used surgical gowns, face shields, and face masks as part of PPE during examining patients and while performing procedure. After treatment 99.3% of participants washed hands with hand wash, soap or used antiseptic solution. 77.1% of participants asked for Covid 19 test report and 68.6% of participants asked for proof of vaccination against covid 19 before treating patients. 96.1% of participants recommended disinfection of dental unit after every patient. 98% of participants changed glove after every patient. 88.2% of the participants said they would carry all elective and emergency procedures. Conclusion: The results of this study show that DHCPs practicing at government sector university have adequate knowledge regarding prevention of cross infection protocols and their importance to limit spread of infections. But their practice of prevention of cross infection during Covid 19 pandemic is not ideal as percentage of DHCPs requiring proof of vaccination or negative reports for Covid 19 were rather low and the percentage of DHCPs willing to carry elective procedures along with emergency ones was rather high. Keywords: Covid 19 pandemic, Omicron virus, cross infection control protocols, omicron

Standard Adult Gastric Emptying Scintigraphy Criteria Is Applicable for Partial Meal Ingestion

BACKGROUND/AIMS

Gastric emptying scintigraphy is commonly performed to assess for dysmotility. A standardized meal with associated threshold criteria was established in 2000 to enable robust interpretation. However, no guidance is available to interpret results when patients do not ingest the entire meal. The purpose of this study is to determine the continued appropriateness of the threshold criteria in contemporary clinical practice and its relevance for partially ingested meals.

METHODS

This retrospective study analyzed patients (n = 1365 total) who underwent solid-phase gastric emptying scintigraphy at an academic medical center. Patients were stratified based on their completion of the standard meal. Patients were further stratified into normal and delayed gastric emptying cohorts based on the current criteria. Percent gastric retention values at 1, 2, 3, and 4 h were compared.

RESULTS

Median (95% upper reference) normal gastric retention values for the complete standard meal were 64% (87%) at 1 h, 25% (60%) at 2 h, 13% (54%) at 3 h and 4% (9%) at 4 h. Consumption of at least 50% of the standard meal yielded similar retention; 53% (86%) at 1 h, 19% (58%) at 2 h, 6% (29%) at 3 h and 3% (10%) at 4 h. There was no significant age- or gender-specific differences using the current criteria, and no differences were observed based on diabetic status. Retention values matched well with the current criteria and validated with data-driven clustering.

CONCLUSION

Adult normative standards for gastric emptying scintigraphy are appropriate for differentiating normal and delayed populations and can be applied to partial meals with at least 50% completion.

Development and implementation of the ECHO model in a school setting to address youth electronic cigarette use in Kansas: A protocol

Introduction

Schools remain at the frontlines of addressing issues, such as e-cigarette use, that impact students. Despite e-cigarette use remaining a significant public health concern in the U.S., schools have limited resources (e.g., staff, capacity, programming) to address it, especially in rural and frontier areas. This ECHO Pilot Project aimed to build capacity and equip schools and school staff in the state of Kansas to address high rates of youth e-cigarette use by providing prevention support and information on best practices for e-cigarette cessation.

Methods and analysis

The pilot used the established Project ECHO model to disseminate evidence-based strategies for e-cigarette prevention and cessation among youth to schools across Kansas. The pilot selected 20 interdisciplinary school teams representing both rural and urban middle and high schools across the state to participate in seven ECHO sessions. ECHO sessions proceeded throughout Fall 2021, with the final session in Spring 2022. School participants completed pre-post surveys as well as component-specific surveys following each ECHO session. In addition, each school team created an individualized action plan to comprehensively address e-cigarette use at their school based on the information provided throughout the ECHO. Survey data, school tobacco/nicotine policies, and action plans will be analyzed to assess process and final outcomes.

Discussion

If successful, this pilot will demonstrate that the ECHO model is an effective platform for building school staff knowledge and skills to implement evidence-based strategies in both urban and rural settings. It is anticipated that the pilot will build capacity and equip schools and school staff to address high rates of youth e-cigarette use by providing support for school-based prevention programs and referrals for e-cigarette cessation which will lessen the burden of nicotine-related problems in Kansas schools and communities. Finally, the pilot will provide evidence that the ECHO model can be successfully and equitably applied in a school setting and may be a viable method for addressing other public health-related issues faced by schools.

THE ORAL HEALTH RELATED HABITS, KNOWLEDGE, AND FREQUENCY OF USE OF DENTAL FLOSS AMONG UNDERGRADUATE DENTAL STUDENTS OF A PUBLIC HEALTH SECTOR UNIVERSITY IN KARACHI, PAKISTAN

Objectives: To assess the gap between knowledge of interdental cleaning aids and the usage of dental floss among dental students. Materials and Methods: A cross-sectional study was undertaken at the Jinnah Sindh Medical University, Sindh Institute of Oral Health Sciences, Karachi, Pakistan, between March to May 2022. Using select statistics electronic software, a sample size of 172 was estimated, however, we included 200 participants in the study considering an expected drop-out rate of 15%. A structured questionnaire was designed to collect data from undergraduate dental students. All data were entered and analyzed using SPSS version 26. Percentages and frequencies were calculated to assess the knowledge and implementation of that knowledge among undergraduate dental students. In Association between the year of study and the use of dental floss, a chi-square test was used. A p-value of < 0.05 was set as the cut-off for statistical significance.   Results: A total of 200 participants were included with 24.5%males and 75.5%females. There was a significant association of interdental cleaning aid awareness with gender (p=0.007). Only a small percentage of females knew that waterjets and rubber tips were interdental cleaning aids while the majority of the respondents irrespective of gender knew that dental floss is interdental cleaning aid. Dental floss usage was significantly higher in the female population than in males (18.37% vs. 50.33%; p=0.019). Conclusion: Our study concluded that while the majority of dental students had knowledge that dental floss should be a routine habit, they themselves were not practicing it. Moreover, about 30% of the study population claimed that they only brushed once a day only. The use of dental floss was significantly more frequent in female dental students. Keywords: interdental cleaning, dental floss, oral health hygiene, dental plaque

Lutetium Lu 177 vipivotide tetraxetan for metastatic castration-resistant prostate cancer

INTRODUCTION

¹⁷⁷Lu-vipivotide tetraxetan is a radiopharmaceutical that selectively targets prostate-specific membrane antigen (PSMA) and delivers beta-radiations to kill prostate cancer cells.

AREAS COVERED

Extensive experience outside the United States as well as randomized phase II and phase III data demonstrate that ¹⁷⁷Lu-vipivotide tetraxetan is a safe, generally well tolerated, and effective therapy for men with mCRPC. ¹⁷⁷Lu-vipivotide tetraxetan was approved by the FDA in March 2022 for the treatment of PSMA-positive metastatic castration-resistant prostate cancer (mCRPC) after androgen receptor pathway inhibition and taxane-based chemotherapy based on the results of the VISION trial.

EXPERT OPINION

This review discusses the development and studies leading to the approval of ¹⁷⁷Lu-vipivotide tetraxetan. In all, ¹⁷⁷Lu-vipivotide tetraxetan is an exciting new tool in the arsenal for men with mCRPC after novel androgen pathway inhibitors and at least one taxane chemotherapy. Optimal selection of patients, sequencing of ¹⁷⁷Lu-vipivotide tetraxetan with the other agents available to treat mCRPC, and the use of dosimetry are current areas of interest with great potential and opportunities for further individual patient optimization using the tools of theranostics.

Mechanisms of APOBEC3 mutagenesis in human cancer cells

The APOBEC3 family of cytosine deaminases has been implicated in some of the most prevalent mutational signatures in cancer^1-3. However, a causal link between endogenous APOBEC3 enzymes and mutational signatures in human cancer genomes has not been established, leaving the mechanisms of APOBEC3 mutagenesis poorly understood. Here, to investigate the mechanisms of APOBEC3 mutagenesis, we deleted implicated genes from human cancer cell lines that naturally generate APOBEC3-associated mutational signatures over time⁴. Analysis of non-clustered and clustered signatures across whole-genome sequences from 251 breast, bladder and lymphoma cancer cell line clones revealed that APOBEC3A deletion diminished APOBEC3-associated mutational signatures. Deletion of both APOBEC3A and APOBEC3B further decreased APOBEC3 mutation burdens, without eliminating them. Deletion of APOBEC3B increased APOBEC3A protein levels, activity and APOBEC3A-mediated mutagenesis in some cell lines. The uracil glycosylase UNG was required for APOBEC3-mediated transversions, whereas the loss of the translesion polymerase REV1 decreased overall mutation burdens. Together, these data represent direct evidence that endogenous APOBEC3 deaminases generate prevalent mutational signatures in human cancer cells. Our results identify APOBEC3A as the main driver of these mutations, indicate that APOBEC3B can restrain APOBEC3A-dependent mutagenesis while contributing its own smaller mutation burdens and dissect mechanisms that translate APOBEC3 activities into distinct mutational signatures.

Use of Fluoro-[18F]-Deoxy-2-D-Glucose Positron Emission Tomography/Computed Tomography to Predict Immunotherapy Treatment Response in Patients With Squamous Cell Oral Cavity Cancers

IMPORTANCE

Neoadjuvant immunotherapy is a novel approach with the potential to improve outcomes for patients with oral cavity squamous cell cancer (OCSCC). Adverse events of varying severity are reported with immunotherapy, and a biomarker to predict response would be clinically useful to avoid toxic effects in those unlikely to benefit.

OBJECTIVE

To correlate changes on fluoro-[18F]-deoxy-2-D-glucose positron emission tomography/computed tomography (FDG-PET/CT) scans with primary tumor pathologic response and immunologic biomarkers in patients with OCSCC receiving neoadjuvant immunotherapy.

DESIGN, SETTING, AND PARTICIPANTS

This was a retrospective analysis of serial FDG-PET/CT scans obtained prospectively as part of a phase 2 open-label randomized clinical trial investigating neoadjuvant immunotherapy in patients with untreated OCSCC between 2016 and 2019. Included were a total of 29 patients from a single academic medical center with untreated OCSCC (≥T2, or clinically node positive) randomized 1:1 to receive neoadjuvant therapy with single agent nivolumab or combination nivolumab and ipilimumab followed by surgery and standard of care adjuvant therapy.

INTERVENTIONS

The interventions in this study were FDG-PET/CT scans before (T0) and after (T1) preoperative immunotherapy.

MAIN OUTCOMES AND MEASURES

Data collected from FDG-PET/CT scans included maximum standardized uptake value (SUVmax) of primary OCSCC and cervical lymph nodes (LNs) at T0 and T1 and new LN uptake and uptake consistent with radiologic immune-related adverse events (irAEs) at T1. Primary OCSCC pathologic response reported as percentages of viable vs nonviable tumor. The number of CD8+ cells/mm2 was determined in the primary tumor biopsy specimen and at surgery.

RESULTS

There was no correlation between pathologic response and change in SUVmax in the primary OCSCC between T0 and T1. Out of 27 total participants, 13 had newly FDG-avid ipsilateral LNs at T1, most negative on pathology. A total of 9 had radiologic irAEs, most commonly sarcoid-like LN (7 of 27). No correlations were found between primary OCSCC SUVmax at T0 and CD8+ T-cell number in the primary tumor biopsy, and no correlations were found between primary OCSCC SUVmax at T1 and CD8+ T-cell number in the primary tumor at surgery.

CONCLUSIONS AND RELEVANCE

There were no correlations between changes in FDG uptake after neoadjuvant immunotherapy and pathologic primary tumor response. Importantly, newly FDG-avid ipsilateral LNs following neoadjuvant immunotherapy were commonly observed but did not represent progressive disease or indicate pathologically disease positive nodes in most cases. These findings argue against altering surgical plans in this setting and suggest that the role of FDG-PET/CT may be limited as an early imaging biomarker for predicting pathologic response to preoperative immunotherapy for OCSCC.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02919683.

Formulation and Evaluation of Miconazole Nitrate Loaded Novel Nanoparticle Gel for Topical Delivery

The aim of the present research work is to design miconazole-loaded chitosan nanoparticles that could potentially assemble in wrinkle and hair follicles to provide prolong release to the skin tissue. The amount of drugs required for the preparation of nanoparticles was determined by studying the entrapment efficiency of preliminary batches. The emulsification/Solvent evaporation method was used for the preparation of nanoparticles. Different proportions of Miconazole Nitrate and Chitosan were dissolved in DCM. The size of the globules in the emulsion was reduced by a high energy shearing using a probe Sonicator at 50 % amplitude for 10 Minutes, followed by the addition of 10 ml 2% PVA. After overnight evaporation of DCM, for isolation of dried NPs, the NPs dispersion was centrifuged at 15,000 RCF for 30 minutes. The obtained particles were dispersed in de-ionized water and freeze-dried. 32 full factorial design was selected for optimization purposes. Prepared batches were evaluated for various parameters such as entrapment efficiency, production yield, particle size, zeta potential, and SEM. F5 batch was found to be optimized which was then used for the preparation of gel. Three levels of Carbopol934 and propylene glycol were used for the optimization of gel. The prepared gel was also evaluated for pH, drug content, viscosity, and spreadability. From the study, it was concluded that nanoparticle gel can be used for the treatment of various skin infections over the conventional gel.