Radiotherapy Standardisation and Artificial Intelligence within the National Cancer Institute's Clinical Trials Network

Artificial intelligence in healthcare refers to the use of complex algorithms designed to conduct certain tasks in an automated manner. Artificial intelligence has a transformative power in radiation oncology to improve the quality and efficiency of patient care, given the increase in volume and complexity of digital data, as well as the multi-faceted and highly technical nature of this field of medicine. However, artificial intelligence alone will not be able to fix healthcare's problem, because new technologies bring unexpected and potentially underappreciated obstacles. The inclusion of multicentre datasets, the incorporation of time-varying data, the assessment of missing data as well as informative censoring and the addition of clinical utility could significantly improve artificial intelligence models. Standardisation plays a crucial, supportive and leading role in artificial intelligence. Clinical trials are the most reliable method of demonstrating the efficacy and safety of a treatment or clinical approach, as well as providing high-level evidence to justify artificial intelligence. The National Surgical Adjuvant Breast and Bowel Project, the Radiation Therapy Oncology Group and the Gynecologic Oncology Group collaborated to form NRG Oncology (acronym NRG derived from the names of the parental groups). NRG Oncology is one of the adult cancer clinical trial groups containing radiotherapy specialty of the National Cancer Institute's Clinical Trials Network (NCTN). Standardisation from NRG/NCTN has the potential to reduce variation in clinical treatment and patient outcome by eliminating potential errors, enabling broader application of artificial intelligence tools. NCTN, NRG and Imaging and Radiation Oncology Core are in a unique position to help with standards development, advocacy and enforcement, all of which can benefit from artificial intelligence, as artificial intelligence has the ability to improve trial success rates by transforming crucial phases in clinical trial design, from study planning through to execution. Here we will examine: (i) how to conduct technical and clinical evaluations before adopting artificial intelligence technologies, (ii) how to obtain high-quality data for artificial intelligence, (iii) the NCTN infrastructure and standards, (iv) radiotherapy standardisation for clinical trials and (v) artificial intelligence applications in standardisation.

A non-dispersive infrared sensor for real-time detection of cyanogen chloride

Cyanogen chloride, as a systemic toxic agent, can cause death rapidly. In this paper, a non-dispersive infrared sensor was designed for the infrared absorption detection of cyanogen chloride at 800 cm−1. The roughness of the internal coating material was analyzed by experiments, and the gold-plated gas chamber was selected. The light path propagation of different cross-section gas chambers was simulated, and the circular section gas chamber was selected to increase the infrared detector signal. The effect of flow rate on voltage was studied. The standard curve between voltage and concentration was obtained under the optimal condition of 0.4 L min−1. The maximum response time was 19 s, and RSD was less than 2%. The interference experiment results showed that common gases entering the gas chamber do not cause interference. The non-dispersive infrared sensor for cyanogen chloride has good stability and detects cyanogen chloride in real-time.

Folic Acid-Modified miR-491-5p-Loaded ZIF-8 Nanoparticles Inhibit Castration-Resistant Prostate Cancer by Regulating the Expression of EPHX1

Epoxide hydrolase 1 (EPHX1) has been reported to be related to the development of several tumors. However, the regulation of castration-resistant prostate cancer (CRPC) development by EPHX1 has not been reported. We used proteomic technology and found that the EPHX1 protein was highly expressed in CRPC tissues and the CRPC cell line C4-2. We performed screening and found that EPHX1 is a direct target of miR-491-5p. High miR-491-5p expression significantly reduced the EPHX1 level in C4-2 cells and inhibited C4-2 cell proliferation and migration. Zeolite imidazolate framework-8 (ZIF-8) has good thermal stability, a simple synthesis method, tumor site stability, and specific acid responsiveness. We synthesized ZIF-8 nanodrug vectors to deliver miR-491-5p into C4-2 cells. After loading miR-491-5p into ZIF-8, we modified the ZIF-8 surface with folic acid (FA) as the target group (FA@ZIF-8). Our synthesized nanodrug carrier showed less cytotoxicity to C4-2 cells even at 200 μg/ml. Modified FA could increase the efficiency of nanomaterial entry into C4-2 cells. FA@miR-491-5p@ZIF-8 could stably release miR-491-5p for a long period in both phosphate-buffered saline (pH 7.4) and acetate buffer (pH 4.8), and miR-491-5p was released faster at the beginning of the experiment in acetate buffer (pH 4.8). FA@miR-491-5p@ZIF-8 significantly reduced C4-2 cell proliferation and migration, and FA@miR-491-5p@ZIF-8 had a better effect than miR-491-5p alone. In vivo, FA@miR-491-5p@ZIF-8 significantly inhibited CRPC growth in nude mice. Overall, we verified that miR-491-4p regulated CRPC development by targeting EPHX1. The drug nanocarrier FA@miR-491-5p@ZIF-8 not only significantly reduced C4-2 CRPC cell proliferation and migration but also significantly inhibited CRPC growth. Our research provides a theoretical basis for treatment and treatment strategies for CRPC.

[Questionnaire investigation of radiation rectal injury with anxiety, depression and somatic disorder]

Objective: To observe the incidence and treatment of radiation rectal injury complicated with anxiety, depression and somatic symptom disorder. Methods: A cross-sectional survey research method was carried out. Patients with radiation rectal injury managed by members of the editorial board of Chinese Journal of Gastrointestinal Surgery were the subjects of investigation. The inclusion criteria of the survey subjects: (1) patients suffered from pelvic tumors and received pelvic radiotherapy; (2) colonoscopy showed inflammatory reaction or ulcer in the rectum. Exclusion criteria: (1) patient had a history of psycho-somatic disease before radiotherapy; (2) patient was unable to use a smart phone, unable to read and understand the questions in the questionnaire displayed on the phone; (3) patient refused to sign an informed consent form. According to the SOMA self-rating scale, PHQ-15 self-rating scale, GAD-7 and PHQ-9 self-rating scale, the electronic questionnaire of "Psychological Survey of Radiation Proctitis" was designed. The questionnaire was sent to patients with radiation rectal injury managed by the committee through the WeChat group. Observational indicators: (1) radiation rectal injury symptom assessment: using SOMA self-rating scale, radiation rectal injury symptom classification: mild group (≤3 points), moderate group (4-6 points) and severe group (> 6 points); (2) incidence of anxiety, depression and physical disorder: using GAD-7, PHQ-9 and PHQ-15 self-rating scales respectively for assessment; (3) correlation of radiation rectal injury symptom grading with anxiety, depression, and somatic symptom disorder. Results: Seventy-one qualified questionnaires were collected, of which 41 (56.9%) were from Guangzhou. Among the 71 patients, 6 were males and 65 were females; the mean age was (55.7±9.3) years old and 48 patients (67.6%) were less than 60 years old; the median confirmed duration of radiation rectal injury was 2.0 (1.0, 5.0) years. (1) Evaluation of symptoms of radiation rectal injury: 18 cases of mild (25.4%), 27 cases of moderate (38.0%), and 26 cases of severe (36.6%). (2) Incidence of anxiety, depression and somatic disorder: 12 patients (16.9%) without comorbidities; 59 patients (83.1%) with anxiety, depression, or somatic disorder, of whom 2 patients only had anxiety, 1 patient only had depression, 9 only had somatic disorder, 2 had anxiety plus depression, 4 had anxiety plus somatic disorder, 2 had depression plus somatic disorder, and 40 had all three symptoms. (3) correlation of radiation rectal injury grading with anxiety, depression, and somatic symptom disorder: as compared to patients in mild group and moderate group, those in severe group had higher severity of anxiety and somatic symptom disorder (Z=-2.143, P=0.032; Z=-2.045, P=0.041), while there was no statistically significant difference of depression between mild group and moderate group (Z=-1.176, P=0.240). Pearson correlation analysis revealed that radiation rectal injury symptom score was positively correlated with anxiety (r=0.300, P=0.013), depression (r=0.287, P=0.015) and somatic symptom disorder (r=0.344, P=0.003). Conclusions: The incidence of anxiety, depression, and somatic symptom disorder in patients with radiation rectal injury is extremely high. It is necessary to strengthen the diagnosis and treatment of somatic symptom disorder, so as to alleviate the symptoms of patients with pelvic perineum pain and improve the quality of life.

Search for Active-Sterile Antineutrino Mixing Using Neutral-Current Interactions with the NOvA Experiment

This Letter reports results from the first long-baseline search for sterile antineutrinos mixing in an accelerator-based antineutrino-dominated beam. The rate of neutral-current interactions in the two NOvA detectors, at distances of 1 and 810 km from the beam source, is analyzed using an exposure of 12.51×10^{20} protons-on-target from the NuMI beam at Fermilab running in antineutrino mode. A total of 121 of neutral-current candidates are observed at the far detector, compared to a prediction of 122±11(stat.)±15(syst.) assuming mixing only between three active flavors. No evidence for ν[over ¯]_{μ}→ν[over ¯]_{s} oscillation is observed. Interpreting this result within a 3+1 model, constraints are placed on the mixing angles θ_{24}<25° and θ_{34}<32° at the 90% C.L. for 0.05  eV^{2}≤Δm_{41}^{2}≤0.5  eV^{2}, the range of mass splittings that produces no significant oscillations at the near detector. These are the first 3+1 confidence limits set using long-baseline accelerator antineutrinos.

[Oxymatrine improves renal fibrosis and inflammation in diabetic rats by modulating CHK1/2 phosphorylation]

OBJECTIVE

To explore the role of cell cycle checkpoint kinase 1/2 (CHK1/2) in mediating the inhibitory effect of oxymatrine (OMT) against renal inflammation and fibrosis in diabetic rats.

METHODS

SD rats were randomly divided into normal control group, diabetes model group (DM) and OMT treatment group (n=6). HE and Masson staining were used to observe histopathological changes of the renal tissue, and the expressions of CHK1, CHK2, p-CHK1 and p-CHK2 were localized by immunohistochemical staining. The contents of interleukin-6 (IL-6) and IL-1β in the renal tissue were detected using ELISA, and the expression levels of CHK1, CHK2, p-CHK1, p-CHK2, type Ⅲ collagen (Col-Ⅲ), type Ⅳ collagen (Col-Ⅳ), and fibronectin (FN) were determined using Western blotting. The changes in the expressions of CHK1, CHK2, p-CHK1, p-CHK2, Col-Ⅲ, Col-Ⅳ and FN proteins were also examined with Western blotting in NRK-52E cells in response to high glucose exposure, OMT treatment and siRNA-mediated CHK1/2 knockdown.

RESULTS

In diabetic rats, OMT treatment significantly decreased the levels of blood glucose, serum creatinine and 24 h urinary protein (P < 0.05) and obviously improved inflammatory cell infiltration and fibrosis phenotype in the renal tissue (P < 0.05). CHK1 and CHK2 were mainly expressed in the cytoplasm and nuclei of renal tubule cells, and their phosphorylation levels were significantly higher in DM group than in the control group and OMT group. OMT treatment significantly decreased the protein expression levels of p-CHK1, p-CHK2, Col-Ⅲ, Col-Ⅳ and FN in the renal tissue of diabetic rats and in NRK-52E cells exposed to high glucose (P < 0.05). In NRK-52E cells, CHK1/2 knockdown resulted in significant reduction of the protein expressions of p-CHK1/2, Col-Ⅲ, Col-Ⅳ and FN (P < 0.05).

CONCLUSION

The inhibitory effects of OMT against renal inflammation and fibrosis in diabetic rats are mediated probably by lowered phosphorylation levels of CHK1 and CHK2, which result in reduced release of the downstream inflammatory mediators and decreased secretion and deposition of extracellular matrix.

Only the NAD precursor nicotinamide riboside maintains cardioprotection under clinically relevant conditions, possibly through activation of glycolysis

Purpose

Cardioprotective strategies against ischaemia-reperfusion injury (IRI) that remain effective in the clinical arena need to be developed. Here, we examined the efficacy of the cardioprotective compounds fingolimod (Fingo), empagliflozin (Empa), melatonin (Mela) and nicotinamide riboside (NR) in the presence of drugs routinely used clinically in IRI conditions such as cardiac by-pass surgery and PCI procedures (opiates, benzodiazepines, P2Y12 antagonist, propofol). Furthermore, we examine the mechanism of protection of effective compound(s).

Methods

Following pilot dose-response curves of each compound, cardioprotective efficacy of Fingo, Empa, Mela and NR in an in vivo rat model employing a clinically relevant anaesthetic background therapy (fentanyl-midazolam) were examined alone or in combination. Drugs were administered 30 min before 25 min left ascending coronary (LAD) ischaemia. Infarct size (IS) was determined following 2 h of reperfusion. Effective treatments were then tested in the presence of a P2Y12 antagonist (cangrelor) or propofol anaesthesia. Finally, the underlying metabolic mechanism of the efficient compound(s) was explored in an ex vivo Langendorff-perfused mouse heart model of cardiac IRI.

Results

We found that among these four compounds, only singular NR was able to reduce IS (30±14% vs 60±16%, P=0.009 vs control, Fig.1A) in vivo in the presence of clinically relevant background anaesthesia. NR still reduced IS in the presence of cangrelor (51±18% vs 71±4%, P=0.016 vs control, Fig.1B), but lost protection in the presence of propofol anaesthesia (62±16% vs 60±14%, P=0.839 vs control, Fig.1C). Furthermore, NR showed protection in the ex vivo model of IRI, where isolated hearts were perfused with glucose (G) and free fatty acid (FFA) palmitate (G+FFA): (IS%: 40±14% vs 64±12%, P=0.003 vs control; LDH release: 28.3±7.2 U/min/GWW vs 37.8±3.7 U/min/GWW, P=0.005 vs control; Rate-Pressure-Product (RPP) recovery (43±12% vs 31±8%, P=0.031 vs control, Fig.2A-C). However, NR's protection was lost when 1) glycolysis was by-passed, by replacing glucose in the perfusate with lactate (L) and pyruvate (P) (LP+FFA) or 2) glycolysis was overly activated by adding insulin to the perfusate (G+FFA+insulin) (Fig.2).

Conclusion

Our data suggests that NR is a promising cardioprotective agent to target cardiac ischaemia-reperfusion injury in clinical conditions employing opioid agonists, benzodiazepines and platelet P2Y12 inhibitors. This protection may, at least partly, be due to NR stimulation of cardiac glycolysis.

Funding Acknowledgement

Type of funding sources: None.

[Trajectories of body mass index Z-score and risk of high blood pressure in late adolescence in Suzhou children]

Objective: To identify age and gender standardized body mass index among children and adolescents and explore their associations with high blood pressure (HBP) in late adolescence. Methods: The current study was based on the Health Promotion Program for Children and Adolescents, school-based surveillance successively conducted from 2012 to 2019 in Suzhou, China. A total of 11 812 children and adolescents aged 16-18 years, who had ≥4 examination records during 2012-2018 and were also involved in a surveillance program in 2019, were included. Latent class growth mixture modeling was used to identify the BMI-Z trajectories in different genders, and multivariate logistic regression was used to analyze the associations between different BMI-Z trajectories and risk of HBP in late adolescence. Results: Six distinct BMI-Z trajectories were determined for both genders:thin, slightly thin,standard, declining, overweight, and obese. Compared with the regular group, the obesity group had 94.0% (OR=1.94, 95%CI: 1.43-2.63) and 107.0% (OR=2.07, 95%CI: 1.33-3.22) increased risk of developing HBP in late adolescence in boys and girls, respectively. However, a neutral association was found between the descending group and HBP in late adolescence. Conclusions: Persistent obesity in children may increase the risk of HBP in their late adolescence. If an obese child restores normal weight before late adolescence, the risk of HBP may reduce.

MiR-466 as a poor prognostic predictor suppresses cell proliferation and EMT in breast cancer cells by targeting PSMA7

OBJECTIVE

MiR-466 has been reported to exert a tumor-suppressive role in several cancers, including colorectal cancer and osteosarcoma, but its clinical significance and functional mechanisms in breast cancer (BC) pathogenesis still remain elusive.

PATIENTS AND METHODS

The expression of miR-466 was determined using reverse transcription quantitative PCR. The clinical significance of miR-466 in BC patients was assessed by Chi-square test, Kaplan-Meier method and Cox regression analyses. Functional experiments, including CCK-8 and transwell assays, were performed to analyze cell proliferation, migration and invasion ability. The association between miR-466 and proteasome subunit α7 (PSMA7) was confirmed by Luciferase reporter assay.

RESULTS

Here, we first observed that the expression of miR-466 was significantly downregulated in BC tissues and cell lines. The decreased miR-466 expression was significantly associated with tumor size (p = 0.003), lymph node metastasis (p = 0.008), TNM stage (p = 0.032) and poor survival rate. In addition, miR-466 was identified as an independent prognostic factor for BC patients. We further found that the overexpression of miR-466 significantly inhibited cell proliferation, migration and invasion. Mechanistically, PSMA7 was a potential target gene of miR-466 and negatively regulated miR-466 in BC cells. Oncomine database and Kaplan-Meier overall survival analysis indicated that upregulation of PSMA7 was associated with poor prognosis of BC patients. The rescue experiments demonstrated that PSMA7 overexpression reversed the effects of miR-466 on cell proliferation, migration, invasion and EMT transcription factors (E-cadherin, N-cadherin, and vimentin).

CONCLUSIONS

Collectively, these results suggest that the miR-466/PSMA7 axis might have potential as a therapeutic target for BC treatment.

Chronic nitrate exposure cause alteration of blood physiological parameters, redox status and apoptosis of juvenile turbot (Scophthalmus maximus)

Nitrate (NO₃^-) is one of the common inorganic nitrogen compound pollutants in natural ecosystems, which may have serious risks for aquatic organisms. However, its toxicological mechanism remains unclear. In the current study, juvenile turbot (Scophthalmus maximus) were exposed to different concentrations of NO₃^- (CK- 3.57 ± 0.16, LN - 60.80 ± 1.21, MN - 203.13 ± 10.97 and HN - 414.16 ± 15.22 mg/L NO₃-N) for 60 d. The blood biochemical assays results revealed that elevated NO₃^- exposure significantly increased the concentrations of plasma NO₃^-, NO₂^-, MetHb, K⁺, cortisol, glucose, triglyceride, lactate, while significantly decreased the concentrations of plasma Hb, Na⁺ and Cl^-, which meant that NO₃^- caused hypoxic stress and further affected the osmoregulation and metabolism in fish. Besides, exposure to MN and HN induced a significant decrease in the level of antioxidants, including SOD (Point: 60th day, MN, HN v.s. CK: 258.36, 203.73 v.s. 326.95 U/mL), CAT (1.97, 1.17 v.s. 2.37 U/mL), GSH (25.38, 20.74 v.s. 37.00 μmol/L), and GPx (85.32, 71.46 v.s. 129.36 U/mL), and a significant increase of MDA (7.54, 9.73 v.s. 5.27 nmol/L), suggesting that NO₃^- exposure leading to a disruption of the redox status in fish. Also, further research revealed that NO₃^- exposure altered the mRNA levels of p53 (HN: up to 4.28 folds) and p53-regulated downstream genes such as Bcl-2 (inferior to 0.44 folds), caspase-3 (up to 2.90 folds) and caspase-7 (up to 3.49 folds), indicating that NO₃^- exposure induced abnormal apoptosis in the fish gills. Moreover, IBRv2 analysis showed that the toxicity of NO₃^- exposure to turbot was dose-dependent, and the toxicity peaked on the 15th day. In short, NO₃^- is an environmental toxicological factor that cannot be ignored, because its toxic effects are long-term and could cause irreversible damage to fish. These results would be beneficial to improve our understanding of the toxicity mechanism of NO₃^- to fish, which provides baseline evidence for the risk assessment of environmental NO₃^- in aquatic ecosystems.

Increased risk of diabetes in cancer survivors: a pooled analysis of 13 population-based cohort studies

BACKGROUND

Diabetes is considered as an established risk factor for cancer development. However, the link between diabetes among cancer survivors remains inconclusive. The hypothesis of this study was to assess the hazard ratio (HR) of incidence of diabetes in cancer survivors compared with the HR in the general population.

PATIENTS AND METHODS

A comprehensive literature search was performed in PubMed, Embase, and the Cochrane Library from database inception to 15 December 2020 for population-based cohort studies. Summary effect estimates were combined using random-effects models. We also performed subgroup analyses to test sources of heterogeneity and the stability of the results stratified by various study and participant characteristics.

RESULTS

Thirteen population-based cohort studies involving 1 686 595 participants were analyzed. The HR for the development of diabetes in cancer survivors was 1.39 [95% confidence interval (CI) 1.29-1.50; I2 = 82.3%; P < 0.001] compared with that in noncancer controls, among which survivors of hematological, gynecologic, breast, colorectal and urinary tract cancer (all P < 0.05) showed consistent significant results, whereas no significant increased risk was observed for other cancer types. The effects were more prominent in populations of shorter cancer survival duration (<1 year) (HR 2.09, 95% CI 1.32-3.32; P = 0.009). Moreover, cancer survivors with a longer follow-up period (>10 years) had a relatively higher risk of diabetes (HR 1.54, 95% CI 1.34-1.77) than those with a shorter follow-up period.

CONCLUSIONS

In this large pooled analysis of population-based cohorts, evidence supports the hypothesis that the risk of developing diabetes is increased in cancer survivors compared with the general population. We should interpret the results with caution for considerable interstudy heterogeneity. However, health policy makers should take this as a challenge for the early prevention and effective intervention of diabetes.

[Establishment of an indicator system for schistosomiasis transmission risk assessment after transmission interruption in Hubei Province based on the Delphi method]

OBJECTIVE

To establish an indicator system for assessment of schistosomiasis transmission risk after transmission interruption in Hubei Province, so as to provide insights into the precise control of schistosomiasis.

METHODS

The indicator system was preliminarily established based on data collection, literature review, expert interviews. Two rounds of expert consultation were performed. The indicator system was screened based on the importance, operability, sensitivity and comprehensive score of the indicators, and the weights of each indicator were calculated. The credibility of the Delphi method was evaluated by calculating the active coefficient of the experts, degree of expert authority and coordination levels of experts' opinions.

RESULTS

An indicator system for assessment of schistosomiasis transmission risk was preliminarily established, including 3 primary indicators, 12 secondary indicators and 44 tertiary indicators. A Delphi consultation was performed among 17 experts participating in schistosomiasis control, management and research. Following two rounds of consultation, a risk assessment indicator system was finally constructed, including 3 primary indicators, 10 secondary indicators and 35 tertiary indicators. Among the primary indicators, the variable with the highest normalized weight was the current status of schistosomiasis (0.420 2), followed by social factors (0.397 3) and natural environments (0.182 5). Among the secondary indicators, those with high combined weights included risk monitoring (0.142 3), current snail status (0.140 1), and current prevalence of human and livestock infections (0.137 8). Among the tertiary indicators, those with high combined weights included the positive rate of wild feces (0.049 8), the prevalence of snail infections (0.047 4), and the area of snail habitats submerged by floods (0.046 8). During the two-round consultation, the active coefficients of the experts were 85.00% and 100.00%, the degree of expert authority was both 0.75 and greater, and the coordination levels of experts' opinions were 0.405 to 0.521 and 0.592 to 0.695 (all P values < 0.05).

CONCLUSIONS

An indicator system for assessment of schistosomiasis transmission risk is successfully established after transmission interruption in Hubei Province based on the Delphi method, which provides insights into the identification of the schistosomiasis transmission risk and the targets for schistosomiasis control in Hubei Province.