Integrated Proteomic and Metabolomic Modules associated with Risk of Kidney Disease Progression

BACKGROUND

Proteins and metabolites play crucial roles in various biological functions and are frequently interconnected through enzymatic or transport processes.

METHODS

We present an integrated analysis of 4,091 proteins and 630 metabolites in the Chronic Renal Insufficiency Cohort Study (N=1,708; average follow-up for kidney failure [KF], 9.5 years, with 537 events). Proteins and metabolites were integrated using an unsupervised clustering method and we assessed associations between clusters and CKD progression and kidney failure using Cox proportional hazards models. Analyses were adjusted for demographics and risk factors including the estimated glomerular filtration rate (eGFR) and urine protein-creatinine ratio. Associations were identified in a discovery sample (random two-thirds, N=1139) and then evaluated in a replication sample (one-third, N=569).

RESULTS

We identified 139 modules of correlated proteins and metabolites, which were represented by their principal components (PC). Modules and PC loadings were projected onto the replication sample which demonstrated a consistent network structure. Two modules, representing a total of 236 proteins and 82 metabolites, were robustly associated with both CKD progression and kidney failure in both discovery and validation samples. Using gene set enrichment, several transmembrane related terms were identified as over-represented in these modules. Transmembrane-ephrin receptor activity displayed the largest odds (OR = 13.2, P-value = 5.5×10 -5 ). A module containing CRIM1 and NPNT expressed in podocytes demonstrated particularly strong associations with kidney failure (P-value = 2.6×10 -5 ).

CONCLUSIONS

This study demonstrates that integration of the proteome and metabolome can identify functions of pathophysiologic importance in kidney disease.

Oral interview in place of traditional objective structured clinical examinations for assessing placement readiness in nutrition and dietetics education

AIM

Objective structured clinical examinations have long been used in dietetics education. This observational study aims to describe the development, deployment, feasibility and validity of assessment using an oral interview in place of traditional objective structured clinical examinations, and to determine the ability of this assessment to identify students who are either not ready for placement or may require early support and/or remediation.

METHODS

Student assessment data were collected over a two-and-a-half-year period and used to test the predictive ability of an oral interview to determine dietetic placement outcomes and highlight a need for early remediation. Descriptive statistics as well as a between-group one-way ANOVA was used to describe results.

RESULTS

A total of 169 students participated in the oral interview and subsequent medical nutrition therapy placement over the study period. Significant differences in oral interview score were seen between students who passed placement and students who passed with remediation or those who failed. Oral interview performance was able to predict placement outcome, yet required less resources than traditional objective structured clinical examinations.

CONCLUSION

An oral interview may provide the same utility as the objective structured clinical examination in dietetics education .

Metabolites Associated With Uremic Symptoms in Patients With CKD: Findings From the Chronic Renal Insufficiency Cohort (CRIC) Study

RATIONALE & OBJECTIVE

The toxins that contribute to uremic symptoms in patients with chronic kidney disease (CKD) are unknown. We sought to apply complementary statistical modeling approaches to data from untargeted plasma metabolomic profiling to identify solutes associated with uremic symptoms in patients with CKD.

STUDY DESIGN

Cross-sectional.

SETTING & PARTICIPANTS

1,761 Chronic Renal Insufficiency Cohort (CRIC) participants with CKD not treated with dialysis.

PREDICTORS

Measurement of 448 known plasma metabolites.

OUTCOMES

The uremic symptoms of fatigue, anorexia, pruritus, nausea, paresthesia, and pain were assessed by single items on the Kidney Disease Quality of Life-36 instrument.

ANALYTICAL APPROACH

Multivariable adjusted linear regression, least absolute shrinkage and selection operator linear regression, and random forest models were used to identify metabolites associated with symptom severity. After adjustment for multiple comparisons, metabolites selected in at least 2 of the 3 modeling approaches were deemed "overall significant."

RESULTS

Participant mean estimated glomerular filtration rate was 43mL/min/1.73m2, with 44% self-identifying as female and 41% as non-Hispanic Black. The prevalence of uremic symptoms ranged from 22% to 55%. We identified 17 metabolites for which a higher level was associated with greater severity of at least one uremic symptom and 9 metabolites inversely associated with uremic symptom severity. Many of these metabolites exhibited at least a moderate correlation with estimated glomerular filtration rate (Pearson's r≥0.5), and some were also associated with the risk of developing kidney failure or death in multivariable adjusted Cox regression models.

LIMITATIONS

Lack of a second independent cohort for external validation of our findings.

CONCLUSIONS

Metabolomic profiling was used to identify multiple solutes associated with uremic symptoms in adults with CKD, but future validation and mechanistic studies are needed.

PLAIN-LANGUAGE SUMMARY

Individuals living with chronic kidney disease (CKD) often experience symptoms related to CKD, traditionally called uremic symptoms. It is likely that CKD results in alterations in the levels of numerous circulating substances that, in turn, cause uremic symptoms; however, the identity of these solutes is not known. In this study, we used metabolomic profiling in patients with CKD to gain insights into the pathophysiology of uremic symptoms. We identified 26 metabolites whose levels were significantly associated with at least one of the symptoms of fatigue, anorexia, itchiness, nausea, paresthesia, and pain. The results of this study lay the groundwork for future research into the biological causes of symptoms in patients with CKD.

Phase 1b study of enzalutamide plus CC-115, a dual mTORC1/2 and DNA-PK inhibitor, in men with metastatic castration-resistant prostate cancer (mCRPC)

BACKGROUND

CC-115, a dual mTORC1/2 and DNA-PK inhibitor, has promising antitumour activity when combined with androgen receptor (AR) inhibition in pre-clinical models.

METHODS

Phase 1b multicentre trial evaluating enzalutamide with escalating doses of CC-115 in AR inhibitor-naive mCRPC patients (n = 41). Primary endpoints were safety and RP2D. Secondary endpoints included PSA response, time-to-PSA progression, and radiographic progression.

RESULTS

Common adverse effects included rash (31.7% Grades 1-2 (Gr); 31.7% Gr 3), pruritis (43.9% Gr 1-2), diarrhoea (37% Gr 1-2), and hypertension (17% Gr 1-2; 9.8% Gr 3). CC-115 RP2D was 5 mg twice a day. In 40 evaluable patients, 80% achieved ≥50% reduction in PSA (PSA50), and 58% achieved ≥90% reduction in PSA (PSA90) by 12 weeks. Median time-to-PSA progression was 14.7 months and median rPFS was 22.1 months. Stratification by PI3K alterations demonstrated a non-statistically significant trend towards improved PSA50 response (PSA50 of 94% vs. 67%, p = 0.08). Exploratory pre-clinical analysis suggested CC-115 inhibited mTOR pathway strongly, but may be insufficient to inhibit DNA-PK at RP2D.

CONCLUSIONS

The combination of enzalutamide and CC-115 was well tolerated. A non-statistically significant trend towards improved PSA response was observed in patients harbouring PI3K pathway alterations, suggesting potential predictive biomarkers of response to a PI3K/AKT/mTOR pathway inhibitor.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02833883.

Enhancing emission control and analyzing the performance and combustion attributes of vehicular engines with spirulina microalgae diesel Ce2O3 nanoparticles blends

The current research investigates the utilization of spirulina microalgae biodiesel blends in a naturally aspirated constant speed compression ignition engine with Ce2O3 nanoparticles at the concentration of 50 ppm under diverse engine loading conditions. Blends of microalgae dispersed with neat diesel at the volume of 20% and 40%. A series of tests were conducted to evaluate the combined effects of microalgae and nanoparticles on engine performance, combustion efficiency, and emission characteristics. The study revealed that increasing the microalgae concentration in the diesel fuel resulted in reduced brake thermal efficiency due to less effective atomization and lower calorific value. Surprisingly, the 20% biodiesel blend with nanoparticles exhibited the highest brake thermal efficiency across various engine loads, while the 40% blend showed higher brake specific fuel consumption compared to both the 20% blend and neat diesel, primarily because of its lower heating value necessitating increased fuel consumption. Furthermore, the biodiesel blends led to lower in-cylinder pressure than pure diesel, mainly attributable to suboptimal atomization. In terms of emissions, the utilization of microalgae-based fuel led to a significant reduction in NOx, CO, and smoke emissions, attributed to the lower cylinder temperatures associated with these blends. In conclusion, this study underscores the potential of spirulina microalgae, particularly when combined with nanoparticles at an optimal concentration, as a promising and environmentally friendly alternative for compression ignition engines.

Proteomics of CKD progression in the chronic renal insufficiency cohort

Progression of chronic kidney disease (CKD) portends myriad complications, including kidney failure. In this study, we analyze associations of 4638 plasma proteins among 3235 participants of the Chronic Renal Insufficiency Cohort Study with the primary outcome of 50% decline in estimated glomerular filtration rate or kidney failure over 10 years. We validate key findings in the Atherosclerosis Risk in the Communities study. We identify 100 circulating proteins that are associated with the primary outcome after multivariable adjustment, using a Bonferroni statistical threshold of significance. Individual protein associations and biological pathway analyses highlight the roles of bone morphogenetic proteins, ephrin signaling, and prothrombin activation. A 65-protein risk model for the primary outcome has excellent discrimination (C-statistic[95%CI] 0.862 [0.835, 0.889]), and 14/65 proteins are druggable targets. Potentially causal associations for five proteins, to our knowledge not previously reported, are supported by Mendelian randomization: EGFL9, LRP-11, MXRA7, IL-1 sRII and ILT-2. Modifiable protein risk markers can guide therapeutic drug development aimed at slowing CKD progression.

Estimated Glomerular Filtration Rate, Albuminuria, and Adverse Outcomes: An Individual-Participant Data Meta-Analysis

Importance

Chronic kidney disease (low estimated glomerular filtration rate [eGFR] or albuminuria) affects approximately 14% of adults in the US.

Objective

To evaluate associations of lower eGFR based on creatinine alone, lower eGFR based on creatinine combined with cystatin C, and more severe albuminuria with adverse kidney outcomes, cardiovascular outcomes, and other health outcomes.

Design, Setting, and Participants

Individual-participant data meta-analysis of 27 503 140 individuals from 114 global cohorts (eGFR based on creatinine alone) and 720 736 individuals from 20 cohorts (eGFR based on creatinine and cystatin C) and 9 067 753 individuals from 114 cohorts (albuminuria) from 1980 to 2021.

Exposures

The Chronic Kidney Disease Epidemiology Collaboration 2021 equations for eGFR based on creatinine alone and eGFR based on creatinine and cystatin C; and albuminuria estimated as urine albumin to creatinine ratio (UACR).

Main Outcomes and Measures

The risk of kidney failure requiring replacement therapy, all-cause mortality, cardiovascular mortality, acute kidney injury, any hospitalization, coronary heart disease, stroke, heart failure, atrial fibrillation, and peripheral artery disease. The analyses were performed within each cohort and summarized with random-effects meta-analyses.

Results

Within the population using eGFR based on creatinine alone (mean age, 54 years [SD, 17 years]; 51% were women; mean follow-up time, 4.8 years [SD, 3.3 years]), the mean eGFR was 90 mL/min/1.73 m2 (SD, 22 mL/min/1.73 m2) and the median UACR was 11 mg/g (IQR, 8-16 mg/g). Within the population using eGFR based on creatinine and cystatin C (mean age, 59 years [SD, 12 years]; 53% were women; mean follow-up time, 10.8 years [SD, 4.1 years]), the mean eGFR was 88 mL/min/1.73 m2 (SD, 22 mL/min/1.73 m2) and the median UACR was 9 mg/g (IQR, 6-18 mg/g). Lower eGFR (whether based on creatinine alone or based on creatinine and cystatin C) and higher UACR were each significantly associated with higher risk for each of the 10 adverse outcomes, including those in the mildest categories of chronic kidney disease. For example, among people with a UACR less than 10 mg/g, an eGFR of 45 to 59 mL/min/1.73 m2 based on creatinine alone was associated with significantly higher hospitalization rates compared with an eGFR of 90 to 104 mL/min/1.73 m2 (adjusted hazard ratio, 1.3 [95% CI, 1.2-1.3]; 161 vs 79 events per 1000 person-years; excess absolute risk, 22 events per 1000 person-years [95% CI, 19-25 events per 1000 person-years]).

Conclusions and Relevance

In this retrospective analysis of 114 cohorts, lower eGFR based on creatinine alone, lower eGFR based on creatinine and cystatin C, and more severe UACR were each associated with increased rates of 10 adverse outcomes, including adverse kidney outcomes, cardiovascular diseases, and hospitalizations.

Factors Underlying Racial Disparity in Utilization of Hepatitis C-Viremic Kidneys in the United States

Utilization of hepatitis C (HCV) viremic kidneys is increasing in the United States. We examined racial disparity in this utilization using UNOS/OPTN data (2014-2020) and mixed effects models adjusting for donor/recipient/center factors. Included in the study were 58,786 adults receiving a deceased donor kidney transplant from 191 centers. Two thousand six hundred thirteen (4%) received kidneys from HCV-viremic donors. Of these, 1598 (61%) were HCV seronegative and 1015 (49%) were HCV seropositive. Among seronegative recipients, before adjusting for waiting time and education, Blacks (OR 0.69, 95%CI (0.60, 0.80)), Hispanics (OR 0.63, 95%CI (0.51, 0.79)), and Asians (OR 0.69, 95%CI (0.53, 0.90)) were less likely than Whites to receive HCV-viremic kidneys. In final models, effect of race was attenuated. Notably, shorter waiting time (OR 0.65, 95%CI (0.63, 0.67)) and increasing educational level (grade school less likely compared to high school OR 0.67, 95% CI (0.49, 0.92) and college more likely than high school (OR 1.16 95% CI (1.02, 1.31)) were associated with receipt of HCV-viremic kidneys. Among HCV-seropositive recipients, recipient race was not independently associated with receipt of HCV-viremic kidneys; however, centers with larger populations of Black waitlisted patients were more likely to utilize HCV-viremic kidneys (OR 1.71, 95%CI (1.20, 2.45)) compared to other centers. Our results suggest recipient race does not independently determine who receives HCV-viremic kidneys; however, other underlying factors including waiting time, education (among seronegative), and center racial mix (among seropositive) contribute to the current differential distribution of HCV-viremic kidneys among races.

Interferon-α promotes neo-antigen formation and preferential HLA-B-restricted antigen presentation in pancreatic β-cells

Interferon (IFN)-α is the earliest cytokine signature observed in individuals at risk for type 1 diabetes (T1D), but its effect on the repertoire of HLA Class I (HLA-I)-bound peptides presented by pancreatic β-cells is unknown. Using immunopeptidomics, we characterized the peptide/HLA-I presentation in in-vitro resting and IFN-α-exposed β-cells. IFN-α increased HLA-I expression and peptide presentation, including neo-sequences derived from alternative mRNA splicing, post-translational modifications - notably glutathionylation - and protein cis-splicing. This antigenic landscape relied on processing by both the constitutive and immune proteasome. The resting β-cell immunopeptidome was dominated by HLA-A-restricted ligands. However, IFN-α only marginally upregulated HLA-A and largely favored HLA-B, translating into a major increase in HLA-B-restricted peptides and into an increased activation of HLA-B-restricted vs. HLA-A-restricted CD8+ T-cells. A preferential HLA-B hyper-expression was also observed in the islets of T1D vs. non-diabetic donors, and we identified islet-infiltrating CD8+ T-cells from T1D donors reactive to HLA-B-restricted granule peptides. Thus, the inflammatory milieu of insulitis may skew the autoimmune response toward epitopes presented by HLA-B, hence recruiting a distinct T-cell repertoire that may be relevant to T1D pathogenesis.

Bioluminescence resonance energy transfer biosensor for measuring activity of a protease secreted by Pseudomonas fluorescens growing in milk

Bacterial proteases are sporadic contributors to milk spoilage, reducing the quality of ultra-heat treated (UHT) milk and other dairy products. Current methods for measuring bacterial protease activity in milk are insensitive and too slow to be used in routine testing in dairy processing plants. We have designed a novel bioluminescence resonance energy transfer (BRET)-based biosensor to measure the activity of proteases secreted by bacteria in milk. The BRET-based biosensor is highly selective for bacterial protease activity compared with other proteases tested, notably including plasmin, which is abundant in milk. It incorporates a novel peptide linker that is selectively cleaved by P. fluorescens AprX proteases. The peptide linker is flanked by green fluorescent protein (GFP²) at the N-terminus and a variant Renilla luciferase (RLuc2) at the C-terminus. Complete cleavage of the linker by bacterial proteases from Pseudomonas fluorescens strain 65, leads to a 95% decrease in the BRET ratio. We applied an azocasein-based calibration method to the AprX biosensor using standard international enzyme activity units. In a 10-min assay, the detection limit for AprX protease activity in buffer was equivalent to 40 pg/mL (≈0.8 pM, 22 μU/mL) and 100 pg/mL (≈2pM, 54 μU/mL) in 50% (v/v) full fat milk. The EC₅₀ values were 1.1 ± 0.3 ng/mL (87 μU/mL) and 6.8 ± 0.2 ng/mL (540 μU/mL), respectively. The biosensor was approximately 800x more sensitive than the established FITC-Casein method in a 2-h assay, the shortest feasible time for the latter method. The protease biosensor is sensitive and fast enough to be used in production settings. It is suitable for measuring bacterial protease activity in raw and processed milk, to inform efforts to mitigate the effects of heat-stable bacterial proteases and maximise the shelf-life of dairy products.

Utilization of the Nannochloropsis microalgae biochar prepared via microwave assisted pyrolysis on the mixed biomass fuel pellets

Nannochloropsis microalgae biochar has become increasingly attractive due to its potential as a component of microalgae-based biodiesel blends. This biochar is a by-product of the pyrolysis process, but its use in the energy sector has been limited. In this study, pellets were formed using microalgae residues and their physiochemical properties were analyzed to assess the feasibility of using microalgae biochar as a fuel source. Three types of biomasses, namely date seed dust, coconut shell waste, and microalgae biochar, were utilized to produce fuel pellets. These pellets were categorized into three types, B1, B2, and B3, based on the composition of the biomass. The inclusion of microalgae biochar in the pellets resulted in enhanced calorific value, as well as improved heating value and bulk density. Moreover, the mechanical strength of microalgae-based pellets was higher due to their high lignin content compared to another biomass. The moisture absorption test results showed that the use of mixed biomass reduced the moisture content over an extended period. Microalgae pellets exhibited higher young's modulus and greater impact resistance, indicating greater mechanical strength. Furthermore, due to their higher calorific value, the combustion time of microalgae pellets was greater than that of other biomass. In conclusion, the results of this study suggest that microalgae biochar can be a promising alternative fuel source for the energy sector.

Daytime Sleepiness Is Associated with Lower Cognitive Scores: The Look AHEAD Study

Background

Daytime sleepiness is common in older adults and may result from poor nighttime sleep due to sleep disordered breathing, fragmented sleep, or other sleep disorders. Daytime sleepiness may be associated with cognition in older adults.

Objectives

We investigated the association between self-reported daytime sleepiness and cognitive function in the Look AHEAD clinical trial.

Design

Observational follow-up of a randomized clinical trial of an intensive lifestyle intervention.

Setting

Clinic.

Participants

Participants (n=1,778) aged 45-76 years at baseline with type 2 diabetes and overweight or obesity.

Interventions

Participants were randomized to an intensive lifestyle intervention for weight loss or a control condition of diabetes support and education.

Measurements

Participants provided self-reported levels of daytime sleepiness at baseline and years 12-13. Cognitive function was assessed with a neurocognitive battery at years 12-13 and 18-20.

Results

Participants who reported having frequent daytime sleepiness (often or always) performed significantly worse than others on the cognitive composite (-0.35; p-value=0.014) after controlling for covariates. When stratified by intervention arm, participants assigned to the intensive lifestyle intervention who reported often/always having daytime sleepiness performed worse on Digit Symbol Coding (-0.63; p-value=0.05) and Trail Making Part-B (-0.56; p-value=0.02) after controlling for covariates. Statistical interactions revealed associations between daytime sleepiness and the following covariates: race and ethnicity, APOE ε4 carrier status, baseline history of cardiovascular disease, and depression.

Conclusions

Daytime sleepiness over ~13 years predicted poorer cognitive performance in older individuals who, by virtue of having diabetes and overweight/obesity, are at high risk for sleep disorders and cognitive impairment.

Antitumor Efficacy of Dual Blockade with Encorafenib + Cetuximab in Combination with Chemotherapy in Human BRAFV600E-Mutant Colorectal Cancer

PURPOSE

Encorafenib + cetuximab (E+C) is an effective therapeutic option in chemorefractory BRAFV600E metastatic colorectal cancer (mCRC). However, there is a need to improve the efficacy of this molecular-targeted therapy and evaluate regimens suitable for untreated BRAFV600E in patients with mCRC.

EXPERIMENTAL DESIGN

We performed a series of in vivo studies using BRAFV600E mCRC tumor xenografts. Mice were randomized to receive 5-fluoruracil (5-FU), irinotecan, or oxaliplatin regimens (FOLFIRI or FOLFOX), (E+C) or the combination. Patients received long-term treatment until disease progression, with deescalation strategies used to mimic maintenance therapy. Transcriptomic changes after progression on cytotoxic chemotherapy or targeted therapy were assessed.

RESULTS

Antitumor activity of either FOLFIRI or E+C was better as first-line treatment as compared with second-line, with partial cross-resistance seen between a cytotoxic regimen and targeted therapy with an average 62% loss of efficacy for FOLFIRI after E+C and a 45% loss of efficacy of E+C after FOLFIRI (P < 0.001 for both). FOLFIRI-treated models had upregulation of epithelial-mesenchymal transition (EMT) and MAPK pathway activation, where E+C treated models had suppressed MAPK signaling. In contrast, with chemotherapy with E+C, EMT and MAPK signaling remained suppressed. FOLFOX or FOLFIRI, each in combination with E+C, were the most active first-line treatments as compared with E+C or to chemotherapy alone. Furthermore, FOLFOX in combination with E+C as first-line induction therapy, followed by E+C ± 5-FU as maintenance therapy, was the most effective strategy for long-term disease control.

CONCLUSIONS

These results support the combination of cytotoxic chemotherapy and molecular-targeted therapy as a promising therapeutic approach in the first-line treatment of BRAFV600E mCRC.

Phytochemical profiling, anti-hyperglycemic, antifungal, and radicals scavenging potential of crude extracts of Athyrium asplenioides- an in-vitro approach

This research was aimed to evaluate the phytochemical profile, antifungal, anti-hyperglycemic, as well as antioxidant activity competence of different extracts of Athyrium asplenioides through in-vitro approach. The A. asplenioides crude methanol extract contained considerable quantity of pharmaceutically precious phytochemicals (saponins, tannins, quinones, flavonoid, phenols, steroid, and terpenoids) than others (acetone, ethyl acetate, and chloroform). Interestingly, the crude methanol extract showed remarkable antifungal activity against Candida species (C. krusei: 19.3 ± 2 mm > C. tropicalis: 18.4 ± 1 mm > C. albicans: 16.5 ± 1 mm > C. parapsilosis: 15.5 ± 2 mm  >  C. glabrate: 13.5 ± 2 mm > C. auris: 7.6 ± 1 mm) at a concentration of 20 mg mL-1. The crude methanol extract also showed remarkable anti-hyperglycemic activity on concentration basis. Surprisingly, remarkable free radicals scavenging potential against DPPH (76.38%) and ABTS (76.28%) free radicals at a concentration of 20 mg mL-1. According to the findings, the A. asplenioides crude methanol extract contains pharmaceutically valuable phytochemicals and may be useful for drug discovery.

Association between Depressive Symptom Trajectory and Chronic Kidney Disease Progression: Findings from the Chronic Renal Insufficiency Cohort Study

Key Points

Depressive symptoms are largely stable over time among individuals with mild-to-moderate CKD Low educational attainment, cigarette smoking, and poor quality of life are associated with persistent depressive symptoms Persistent depressive symptoms are associated with nonlinear and rapid decline in kidney function

Background

Although depression is highly prevalent among individuals with CKD, little is known about the course of depressive symptoms over time. We characterized trajectories of depressive symptoms and CKD progression and evaluated the association between depressive symptoms trajectory and CKD progression.

Methods

Two thousand three hundred sixty-one individuals with mild-to-moderate CKD enrolled in the Chronic Renal Insufficiency Cohort Study were analyzed. The Beck Depression Inventory (BDI) was used to assess depressive symptoms at baseline and biennially. Higher BDI scores indicate worse depressive symptoms. eGFR was calculated using the 2021 CKD-EPI equation. Group-based trajectory models were used to determine trajectories of BDI score and eGFR change over time. Multinomial logistic regression was used to examine factors associated with BDI trajectories and to evaluate the association of BDI trajectories with eGFR change.

Results

Over 8 years of follow-up, three patterns of depressive symptoms were identified: persistently low BDI score (57.7%), persistently moderate BDI score (33.1%), and persistently high BDI score (9.2%). Three eGFR trajectory groups were identified: nonlinear, rapid eGFR decline (21.5%); linear, expected eGFR decline (54.8%); and stable eGFR (23.7%). Predictors of persistently moderate and high BDI trajectories included low educational attainment, smoking, and poor quality of life. Compared with those with a persistently low BDI score, the odds for nonlinear, rapid eGFR decline were higher for those with persistently moderate BDI scores (odds ratio [OR], 1.45; 95% confidence interval [CI], 1.04 to 2.03) and persistently high BDI scores (OR, 1.90; 95% CI, 1.02 to 3.56). No association between moderate BDI score and linear, expected eGFR decline was observed.

Conclusions

Depressive symptoms remained largely stable among individuals with mild-to-moderate CKD, and persistently moderate and high BDI scores were associated with nonlinear, rapid eGFR decline. Future work is needed to better understand the interplay between depression and CKD progression.

Optimizing engine performance and reducing emissions of greenhouse gases through spirulina microalgae and nano-additive blends

The shift in focus towards biofuels has led to the attention towards fourth-generation fuels, particularly microalgae, due to its high oil productivity and simple cultivation processes. The current study aimed to examine the effects of spirulina microalgae blends in a naturally aspirated diesel engine by testing two blend percentages (15% and 30%) and incorporating Fe₂O₃ nanoparticles (75 ppm). A series of test conducted in a single-cylinder engine with an optimum compression ratio of 17.5. The fuels tested include 100% diesel (D0), diesel with Fe₂O₃ nanoparticles (DF), diesel with 15% microalgae blends (B15), diesel with 15% microalgae blends and Fe₂O₃ nanoparticles (B15F), diesel with 30% microalgae blends (B30), and diesel with 30% microalgae blends and Fe₂O₃ nanoparticles (B30F). The results showed that the addition of microalgae blends led to a marginal increase in engine performance, while the addition of Fe₂O₃ nanoparticles led to a significant increase in brake thermal efficiency and decreased fuel consumption. The emissions rate was also lower compared to diesel, but the addition of Fe₂O₃ nanoparticles increased the oxygen content in the fuel, thereby improving the combustion rates. By ensuring the complete combustion the formation of CO₂, HC and smoke intensity was also found to be significantly lower compared to diesel fuel. On the contrary, NOx increased due to the cylinder temperatures. This research highlights the potential of using microalgae as a sustainable source of biofuel, and the positive effects of adding Fe₂O₃ nanoparticles to enhance the fuel's efficiency.

Abstract P6-01-17: A single-center prospective cohort study to evaluate circulating tumor cells as a monitoring tool in women with breast cancer treated with neoadjuvant chemotherapy

Background The presence of circulating tumor cells (CTCs) among women before and/or after completion of neoadjuvant chemotherapy (NAC) for breast cancer may be associated with an increased risk of recurrence, but limited data is available. Objectives To use the Epic Sciences platform to detect and enumerate CTCs in blood samples from women with a new diagnosis of non-metastatic breast cancer of any subtype both i) prior to commencing NAC, and ii) after completion of NAC and surgery. Methods Inclusion criteria included women of any age with non-metastatic breast cancer of any subtype who have not yet commenced NAC. Those diagnosed with prior invasive cancer at any site (apart from non-melanoma skin cancer diagnosed more than five years prior to enrollment) were excluded. Blood samples were obtained to measure CTCs prior to NAC and after NAC and surgery, respectively. CTC identification was based on immunofluorescence analysis using Epic Sciences platform as previously described (Ueno et al 2017). The presence of CTCs was correlated with clinical/pathological data and treatment response, which were abstracted from patients’ medical records. The association between the presence of CTCs and clinical/pathologic characteristics was tested using Fisher’s exact test for categorical variables and t-test or Wilcoxon rank sum tests for numerical variables. All analyses were performed using the R software package. An ad-hoc preliminary analysis was conducted among the first 34 of 50 participants. Results 41 patients (out of an intended 50) have been recruited to-date. 34 participants have a pre- and/or post-treatment CTC measurement available, but 1 was excluded because it was identified to have metastatic disease shortly after enrollment. Among 33 evaluable patients without metastatic disease, 6 (19%) had triple negative breast cancer (TNBC), 13 (39%) had HER2+ and 13 (39%) had hormone receptor (HR)+/HER2- breast cancer. Most (94%) received anthracycline and taxane-based NAC. The median age of breast cancer diagnosis was 50 (29-75). A total of 53 samples were tested for CTC enumeration (5 mL per sample) including 33 pre-treatment and 20 post-treatment samples. CTCs were detected in 32 samples (n=32/53, 60%), including 24 pre-NAC (n=24/33, 73%) with a median of 0.9 CTCs per mL (0.2-19) and 8 post-NAC and surgery (n= 8/20, 40%) with a median of 0.6 CTCs per mL (0.3-3.3). Among the 24 patients (73%) who had detectable CTCs pre-NAC, 10 had HR+/HER2- (41.7%), 9 had HER2+ (37.5%) and 4 (16.7%) had triple negative disease. Among the 20 patients for whom matched pre- and post-treatment CTC results were available, 16 (80%) had detectable CTCs pre-treatment and 8 (40%) had detectable levels post-NAC and surgery. Among the 8 patients (40%) for whom CTCs were detectable post NAC and surgery, 4 (50%) had HR+/HER2-, 2 had HER2+ (25%) and 2 (25%) had triple negative disease. 3 of these patients had numerically higher CTC levels after completion of NAC and surgery compared to pre-NAC levels, 2 of whom had HR+/HER2- breast cancer and one of whom had TNBC. A total of 7 of 33 patients achieved a pathological complete response (PCR) to NAC, among whom 3 had matched pre- and post-treatment CTC results available; none of these 3 patients had detectable CTCs post-treatment. Conclusions Approximately 3 in 4 women with non-metastatic breast cancer who undergo NAC have detectable CTCs pre-treatment using the Epic Sciences Platform. Of 20 patients with matched pre-/post-treatment results, a high proportion (40%) have persistently detectable CTCs. Hence, CTCs may represent an additional measure of minimal residual disease for patients undergoing NAC for breast cancer.

Citation Format: Rania chehade, Arushi Jain, Veronika Moravan, Giuseppe Di Caro, Amanda Anderson, Megan M. Slade, Rick Wenstrup, Ana Elisa Lohmann, William Tran, Katarzyna Jerzak. A single-center prospective cohort study to evaluate circulating tumor cells as a monitoring tool in women with breast cancer treated with neoadjuvant chemotherapy [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P6-01-17.

Abstract P5-05-09: Multianalyte liquid biopsy to aid the diagnostic workup of breast cancer

Breast cancer (BC) affects 1 in every 8 women in the United States and is currently the most prevalent cancer worldwide. Precise staging at diagnosis and prognosis are essential components for the clinical management of BC patients. The liquid biopsy (LBx) has promising applications in cancer screening and early diagnosis ultimately leading to better survival results and less disease burden. In this study, we evaluated the feasibility of the high-definition single cell assay (HDSCA) LBx platform to stratify disease states (early- and late-stage BC) and normal donors using peripheral blood samples. In the HDSCA3.0 workflow, both common white blood cells (WBCs) and rare cells, including circulating tumor cells (CTCs), EMT and platelet-coated cells, plus acellular structures are identified and classified computationally from scanned immunofluorescent images. This comprehensive LBx approach provides a quantitative landscape view of each individual case. In a striking example of the insight provided by HDSCA, we compared LBx results for early-stage and late-stage BC patients with two independent cohorts of normal donors to show the utility of a blood draw as a source of biomarkers for early-stage cancer detection. As expected, CTCs were detected at a higher level in late-stage patients, compared to either the early-stage or normal donors. Surprisingly, however, we observed a significantly higher incidence of tumor-associated large extracellular vesicles (LEVs) in the early-stage patients, compared to the other two groups. A patient-level classification model was able to correctly classifying LBx profiles as normal, early, or late with LEV enumeration as the strongest predictor, followed by epi.CTC enumeration. We will present a reproducible LBx profile of rare cells and LEVs of early-stage disease compared to late-stage BC and normal donors with high accuracy, allowing for robust stratification. Our findings illustrate the feasibility of the LBx to assess early disease states prior to clinically defined metastasis, stratified from normal donors, highlighting the general consideration of the liquid biopsy for the diagnostic work-up and potentially screening.

Citation Format: Stephanie Shishido, Peter Kuhn, Jeremy Mason, James Hicks, Rafael Nevarez, Nicholas Matsumoto, Anand Kolatkar, Carmen Ruiz Velasco, Amanda Anderson, Michael Kidd, Kathy Wilkinson, E Shelley Hwang, Janice Lu, Jorge Nieva, Nikki Higa, Amin Naghdloo, Olivia Hart, Sonia Maryam Setayesh. Multianalyte liquid biopsy to aid the diagnostic workup of breast cancer [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P5-05-09.

The utility of an interprofessional education framework and its impacts upon perceived readiness of graduates for collaborative practice. A multimethod evaluation using the context, input, process, product (CIPP) model

BACKGROUND

Frameworks in higher education can support strategic curriculum change in complex systems. The impact of these frameworks in achieving their stated purpose is less known. An interprofessional education (IPE) framework and related multi-activity curriculum designed to develop health profession graduates with the requisite skills for collaborative care, was introduced in a large university, across eleven health professions.

OBJECTIVE

To determine the utility of an interprofessional framework and impact upon perceived work readiness for collaborative practice.

METHOD

A multimethod design using the context, input, process, product (CIPP) evaluation model was selected taking a social constructivist theoretical stance. Data collection included staffing allocation to IPE, curriculum audit, and reflections from representatives of all health professions courses offered at the institution. Data was analyzed using framework analysis.

PARTICIPANTS

Interviews or focus groups were undertaken with academic Faculty (n = 13), recent graduates (n = 24) and clinical supervisors/employers of recent graduates (n = 17).

RESULTS

The framework assisted the systematic implementation of interprofessional curriculum across the different health courses at the university. Collaborative work-ready learning outcomes were identified in graduates where targeted curriculum had been implemented across all four domains of the framework. Gaps identified in framework implementation were consistent with gaps identified in graduate knowledge and skills related to collaborative practice. The combination of formal university-based IPE and informal workplace learning as part of clinical placements contributed to achieving the desired learning outcomes.

CONCLUSIONS

These findings offer insights into the use of shared frameworks to drive specific learning activities related to collaborative practice.

Evaluating natural planned exposure protocols on rotavirus shedding patterns in gilts and the impact on their suckling pigs

Objective: The objectives of this study were to determine the pattern of rotavirus A (RVA), rotavirus B (RVB), and rotavirus C (RVC) shedding in gilts after natural planned exposure (NPE) administration and assess the effects on piglet weaning weight, preweaning mortality, and RV shedding. Materials and methods: A total of 70 pregnant gilts were enrolled and allocated into 4 groups. Group 1 was given NPE at 5, 4, and 3 weeks prefarrowing (WPF); Group 2 at 5 and 3 WPF; and Group 3 at 5 WPF only. Group 4 (control group) did not receive any NPE. Samples from 46 gilts and litters (5 piglets/litter) were tested at 12 sample times. Piglets were sampled weekly from 24 hours of age until 6 weeks of age and tested by quantitative reverse transcriptase-polymerase chain reaction for RVA, RVB, and RVC. Results: There was a significant improvement in weaning weight of piglets born to gilts that received 3 NPE administrations compared to fewer or no NPE administrations. Shedding of RVA and RVB from piglets were well controlled in the farrowing room regardless of treatment group, but RVC was observed as early as 1 week old. This study was conducted on a single farm, and the results should be carefully interpreted with knowledge of variations in farms and systems. Implications: Three administrations of NPE to gilts prefarrowing had valuable production and economic benefits for the producer. Circulation patterns of RVA, RVB, and RVC appear to correlate; interventions for one have value against the others.

Evaluation of 137Cs, 133Xe and 3H activity concentrations monitored in the Arctic atmosphere

This paper provides a brief introduction to the Arctic atmospheric radioactivity monitoring network. A decade of monitoring results have shown the ¹³⁷Cs background levels in Arctic air range from 0.05 to 1.50 μBq/m³. The monitoring stations have sufficient sensitivity to detect ¹³⁷Cs brought to the atmosphere due to resuspension in local soil and reemissions from biomass burning in a daily temporal resolution. These observations can be used as tracers for atmospheric processes. The ¹³³Xe measurements obtained at Yellowknife, Resolute and Spitsbergen could support other research into how air pollution problems arise across intercontinental distances. It will help develop and improve models capable of predicting the long-distance transport and deposition of trace gases in the Arctic. Rainwater monitoring data collected in Finnish Lapland since the 1960's indicate that ³H radioactivity concentrations reached natural background levels in early 2000s, typically around 1-2 Bq/L monthly, with an annual seasonal variation cycle consistent with the observed of other cosmogenic radionuclides.

Autologous humanized mouse models to study combination and single-agent immunotherapy for colorectal cancer patient-derived xenografts

Designing studies of immunotherapy is limited due to a lack of pre-clinical models that reliably predict effective immunotherapy responses. To address this gap, we developed humanized mouse models of colorectal cancer (CRC) incorporating patient-derived xenografts (PDX) with human peripheral blood mononuclear cells (PBMC). Humanized mice with CRC PDXs were generated via engraftment of autologous (isolated from the same patients as the PDXs) or allogeneic (isolated from healthy donors) PBMCs. Human T cells were detected in mouse blood, tissues, and infiltrated the implanted PDXs. The inclusion of anti-PD-1 therapy revealed that tumor responses in autologous but not allogeneic models were more comparable to that of patients. An overall non-specific graft-vs-tumor effect occurred in allogeneic models and negatively correlated with that seen in patients. In contrast, autologous humanized mice more accurately correlated with treatment outcomes by engaging pre-existing tumor specific T-cell populations. As autologous T cells appear to be the major drivers of tumor response thus, autologous humanized mice may serve as models at predicting treatment outcomes in pre-clinical settings for therapies reliant on pre-existing tumor specific T-cell populations.

The Utility of Flexion-Extension Radiographs in Degenerative Cervical Spondylolisthesis

STUDY DESIGN

Retrospective radiologic analysis.

OBJECTIVE

The aim was to investigate if lateral flexion-extension radiographs identify additional cases of degenerative cervical spondylolisthesis (DCS) that would be missed by obtaining solely neutral upright radiographs, and determine the reliability of magnetic resonance imaging (MRI) in diagnosis.

SUMMARY OF BACKGROUND DATA

DCS and instability can be a cause of neck pain, radiculopathy, and even myelopathy. Standard anteroposterior and lateral radiographs and MRI of the cervical spine will identify most cervical spine pathology, but spondylolisthesis and instability are dynamic issues. Standard imaging may also miss DCS in some cases.

METHODS

We compared the number of patients who demonstrated cervical spondylolisthesis on lateral neutral and flexion-extension radiographs in addition to MRI. We used established criteria to define instability as ≥2 mm of listhesis on neutral imaging, and ≥1 mm of motion between flexion-extension radiographs.

RESULTS

A total of 111 patients (555 cervical levels) were analyzed. In all, 41 patients (36.9%) demonstrated cervical spondylolisthesis on neutral and/or flexion-extension radiographs. Of the 77 levels of spondylolisthesis, 17 (22.1%) were missed on neutral radiographs ( P ,0.05). Twenty levels (26.0%) were missed when flexion-extension radiographs were used alone ( P =0.02). Twenty-nine levels (37.7%) of DCS identified on radiograph were missed by MRI ( P =0.004).

CONCLUSIONS

Lateral flexion-extension views can be useful in the diagnosis of DCS. These views provide value by identifying a significant cohort of patients that would be undiagnosed based on neutral radiographs alone. Moreover, MRI missed 38% of DCS cases identified by radiographs. Therefore, lateral radiographs can be a useful adjunct to neutral radiographs and MRI when instability is suspected or if these imaging modalities are unable to identify the source of a patient's neck or arm pain.

Assessing the incidence of osteosarcoma among teriparatide-treated patients using linkage of commercial pharmacy and state cancer registry data, contributing to the removal of boxed warning and other labeling changes

BACKGROUND

Teriparatide, a recombinant human parathyroid hormone analogue, is associated with increased bone mineral density and a decreased risk of fractures. A dose-dependent increase in the incidence of osteosarcoma was observed in toxicology studies conducted in rats. The primary objective of this study was to estimate the incidence of osteosarcoma over a 10-year period among teriparatide-treated patients versus patients unexposed to teriparatide with osteoporosis and patients in the general population using national pharmacy dispensing data linked with data from participating state cancer registries (SCRs) in the US.

METHODS

Patients aged 18 years or older with a dispensed teriparatide prescription formed two different cohorts: Teriparatide-Osteoporosis (Teriparatide-OP) was formed by matching teriparatide patients to unexposed patients with osteoporosis and Teriparatide-General Population (Teriparatide-GP) was formed by matching teriparatide patients to general population patients with a dispensed prescription for a medication other than teriparatide. Matching was performed using select demographics and other variables. Study cohorts were linked to SCR data to ascertain osteosarcoma status. To account for missing outcome data from non-participating SCRs, two analytic approaches were used: the first adjusted the person-time at-risk using a coverage fraction and the second restricted the analyses to patients from states with participating SCRs.

RESULTS

There were 18 osteosarcoma cases across four study cohorts: the same three cases in the Teriparatide-OP and Teriparatide-GP cohorts, six cases in the Osteoporosis cohort, and nine cases in the General Population cohort. For the analysis using the coverage fraction the incidence rate ratio (IRR) comparing the Teriparatide-OP and Teriparatide-GP cohorts to the Osteoporosis and General Population cohorts was 1.0 (95% CI: 0.2, 4.5) and 1.3 (95% CI: 0.2, 5.1), respectively. When restricting the analysis to patients from states with participating SCRs, the IRR was 0.6 (95% CI: 0.1, 3.6) and 0.8 (95% CI 0.1, 4.0), respectively.

CONCLUSION

The estimates of association between teriparatide and osteosarcoma were imprecise due to the small number of observed osteosarcoma cases. However, the incidence of osteosarcoma observed in each study cohort was within the expected range given background rates for the US general population. The evidence generated by this study, in conjunction with other real-world studies evaluating the risk of osteosarcoma, was used to support changes to the US teriparatide label (including removal of the black box warning regarding potential risk of osteosarcoma) and expand treatment options for patients with osteoporosis.

Multianalyte Prognostic Signature Including Circulating Tumor DNA and Circulating Tumor Cells in Patients With Advanced Pancreatic Adenocarcinoma

PURPOSE

Pancreatic ductal adenocarcinoma (PDAC) is associated with a poor prognosis. Multianalyte signatures, including liquid biopsy and traditional clinical variables, have shown promise for improving prognostication in other solid tumors but have not yet been rigorously assessed for PDAC.

MATERIALS AND METHODS

We performed a prospective cohort study of patients with newly diagnosed locally advanced pancreatic cancer (LAPC) or metastatic PDAC (mPDAC) who were planned to undergo systemic therapy. We collected peripheral blood before systemic therapy and assessed circulating tumor cells (CTCs), cell-free DNA concentration (cfDNA), and circulating tumor KRAS (ctKRAS)-variant allele fraction (VAF). Association of variables with overall survival (OS) was assessed in univariate and multivariate survival analysis, and comparisons were made between models containing liquid biopsy variables combined with traditional clinical prognostic variables versus models containing traditional clinical prognostic variables alone.

RESULTS

One hundred four patients, 40 with LAPC and 64 with mPDAC, were enrolled. CTCs, cfDNA concentration, and ctKRAS VAF were all significantly higher in patients with mPDAC than patients with LAPC. ctKRAS VAF (cube root; 0.05 unit increments; hazard ratio, 1.11; 95% CI, 1.03 to 1.21; P = .01), and CTCs ≥ 1/mL (hazard ratio, 2.22; 95% CI, 1.34 to 3.69; P = .002) were significantly associated with worse OS in multivariate analysis while cfDNA concentration was not. A model selected by backward selection containing traditional clinical variables plus liquid biopsy variables had better discrimination of OS compared with a model containing traditional clinical variables alone (optimism-corrected Harrell's C-statistic 0.725 v 0.681).

CONCLUSION

A multianalyte prognostic signature containing CTCs, ctKRAS, and cfDNA concentration outperformed a model containing traditional clinical variables alone suggesting that CTCs, ctKRAS, and cfDNA provide prognostic information complementary to traditional clinical variables in advanced PDAC.

Improved sensitivity in identification of first recurrences of metastatic breast cancer with a combination of cell and cell-free liquid biopsy analysis

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Background: Liquid biopsy analysis detecting circulating tumor cells (CTC) or circulating tumor DNA (ctDNA) is a non-invasive approach that may provide clinically actionable information for patients’ (pts) treatment decisions when conventional biopsy is otherwise inaccessible or infeasible. Here we report a liquid biopsy method including CTC characterization & ctDNA alterations in pts symptomatic of first metastatic recurrence with a history of primary breast cancer (BC). Methods: Blood samples from 34 symptomatic BC pts were collected for cell & cell-free DNA analysis before undergoing contemporaneous tissue biopsy & initiating treatment for metastatic BC (MBC). Blood was also collected from 25 blood donors (HD) with no known cancer history. After plasma isolation, nucleated cells were plated, & slides were bio-banked. Immunofluorescent staining & subsequent imaging were performed on replicate slides. CTCs were identified using Epic Sciences digital imaging & machine learning algorithms trained to identify breast cancer cells. Single-cell (sc) isolation for genomic quantification of large-scale transitions (scLST) was used to further characterize individual CTCs. cfDNA from bio-banked plasma was analyzed to detect Class IA alterations in ctDNA. Results: Within this cohort of 34 patients, CTCs & ctDNA alterations were detected in 80% & 58%, respectively while no CTCs & ctDNA were detected in the HD cohort suggesting high specificity (100% & 100%). In this study, 26 pts were confirmed MBC (M1-BC) by tissue biopsy, 3 pts were non-MBC by tissue biopsy but still diagnosed as metastatic (Mx-BC), & 5 pts were confirmed non-MBC (M0-BC). To benchmark the cellular (CTCs & scLST+CTCs) & genomic (ctDNA) individual platforms, we designed thresholds of CTCs > 4, scLST+CTC+, & ctDNA+ that optimally identified M1-BC pts with high specificity (100%, 100%, & 100%) but low sensitivity (46%, 46%, & 50%). CTCs > 4 & scLST+CTC+ cutoffs had low concordance with the presence of ctDNA alterations, suggesting these platforms provide independent & complementary value when identifying MBC. To test this hypothesis, we designed combination models [CTC > 4][ctDNA+] & [scLST+CTC+][ctDNA+] that significantly improved sensitivity (75% & 67%) over individual platforms while maintaining high specificity (100% & 100%) when identifying the first recurrence of metastasis in BC pts. Conclusions: To our knowledge, this is the first report showing the additive & complementary value of models combining cellular & genomic liquid biopsy platforms for the detection of the first MBC recurrence. Our data suggest the clinical utility of combined CTC & ctDNA platforms for the identification of MBC when tissue biopsy is inaccessible or infeasible.

Chromosomal instability (CIN) in circulating tumor cells (CTC) predicts for taxane sensitivity in metastatic castration-resistant prostate cancer (mCRPC)

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Background: Few clinically validated biomarkers can inform therapy (tx) sequencing in mCRPC. Previously, we credentialed a biomarker of CIN in individual CTCs using phenotypic identification of cells with ≥9 large scale transitions (LSTs) and classification of CIN as high when detected in ≥3 CTC/mL (CIN3+). CIN3+ was associated with shorter radiographic progression survival (rPFS) and overall survival (OS) following taxane (T) or androgen receptor signaling inhibitor (ARSi) tx in mCRPC. Similarly, high CIN defined as ≥1 CTC/mL with ≥9 LSTs (CIN1+) predicts worse rPFS and OS following ARSi. Here, we explored if CIN1+ or CIN3+ predicted differential outcomes in pts on-tx with T or ARSi for mCRPC. Methods: We analyzed 208 banked CTC samples from 173 mCRPC pts collected within 30 days prior to starting a new tx with either T (n=88) or ARSi (n=120) in 2012-2017. CTCs were detected using Epic Sciences platform and CIN defined using the phenotypic classifier (PMID 32816908). Retrospective clinical annotation was completed for OS, defined as time from index tx start date to death, and rPFS, defined as index date to date of new or/and increasing lesion size in on-tx radiology report or death. Associations with rPFS and OS were studied according to samples’ CIN1+ and CIN3+ status. T vs. ARSi comparisons were adjusted using Cox models that incorporated pre-tx covariates, i.e. prior T or ARSi txs, total CTC count, presence of visceral disease, and prognostic lab values. Results: The median (range) follow-up from tx start to date of death or last follow-up was 7 (5-9) years. There were 53/120 (44%) pts starting ARSi that had prior ARSi txs and 41/88 (46%) pts starting taxane that had prior taxane txs. CTCs were detected in 184 (88%) samples, CIN1+ in 73 (35%; 64% pre-T, 36% pre-ARSi), and CIN3+ in 47 (22%; 60% pre-T,40% pre-ARSi). Compared to CIN1+, model results (Table) suggest that CIN3+ predicts a longer rPFS (p<0.01), and possibly OS (p=0.05), with T therapy. Compared to CIN1-, CIN3- also predicts a longer OS with ARSi therapy (p=0.04). Conclusions: CIN3+ CTC may be a more discriminating predictive biomarker than CIN1+ to help guide selection of T or ARSi tx in pts with mCRPC. Adequately powered prospective studies are planned. [Table: see text]

Demonstration of the value of liquid biopsy to identify metastatic breast cancer: Comparison and combination of cell and cell-free platforms

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Background: Liquid biopsy analysis detecting circulating tumor cells (CTC) or circulating tumor DNA (ctDNA) is a non-invasive approach that may provide clinically actionable information for patients’ (pts) treatment decisions when conventional biopsy is otherwise inaccessible or infeasible. Here we report a liquid biopsy analysis method including CTC characterization and ctDNA alterations in late-stage metastatic breast cancers (MBC). Methods: Blood samples were collected for cell and cell-free DNA analysis from 57 pts with MBC. 44 pts were progressing on treatment and 13 were responding to treatment. Blood was also collected from 25 blood donors (HD) with no known cancer history. After plasma isolation, nucleated cells were plated, and slides were bio-banked. Immunofluorescent staining and subsequent imaging were performed on replicate slides. CTCs were identified using Epic Sciences digital imaging and machine learning algorithms trained to identify breast cancer cells. Single-cell (sc) isolation for genomic quantification of large-scale transitions (scLST) was used to further characterize individual CTCs. cfDNA from bio-banked plasma was analyzed using a validated NGS panel to detect class 1A ctDNA alterations. Results: Within this cohort of 57 MBC pts, CTCs, scLST+CTCs and ctDNA alterations were detected in (77%, 49% and 33%, respectively). All MBC pts on active therapy (23%) had no CTC detected. No CTCs, scLST+CTCs or ctDNA were detected in the HD cohort, suggesting high specificity (100%, 100% and 100%, respectively). The presence of CTCs or of scLST+CTCs had low concordance with the presence of ctDNA+ alterations in MBC pts, suggesting that these platforms provide independent and complementary value when identifying MBC. To test this hypothesis, we designed combination models which added ctDNA to cell analysis methods ([CTC+][ctDNA+] and [scLST+CTC+][ctDNA+]). Adding ctDNA to either cell analysis method increased sensitivity by 5% and 12%, respectively, over the individual methods and retained 100% specificity. Conclusions: Here we demonstrate the value of comprehensive cell and cell-free liquid biopsy analysis for the detection of MBC pts. Our data suggest there may be clinical utility of adding cell-free to cell analysis for the identification of MBC. Analysis of the comparative and combined utility of these liquid biopsy methods in earlier settings is ongoing.

Treatment of heavy metals containing wastewater using biodegradable adsorbents: A review of mechanism and future trends

The direct disposal of industrial effluents into the aquatic system is considered as a significant environmental hazard in many countries. Because of poisonous chemicals, substantial volumes of effluent release, as well as the lack of adequate of conventional treatment methodologies, industrial effluent treatment is extremely difficult. Numerous researchers have been interested in adsorption technology for its high efficiency of pollutant removal, low cost, and abundantly available adsorbent. Various adsorbent materials, both natural and modified form, have been widely used for the removal of toxic contaminants from industrial effluent. This paper highlights recent advancements in multiple modification types to functionalize the adsorbent material, resulting in higher adsorption capacity on various toxic pollutants. This review provides an overview of the adsorption mechanism and parameters (pH, adsorbent dosage, initial concentration, temperature and interaction time), which influencing the removal efficiency of adsorbents. Furthermore, this review compiles the desorption study to recover the adsorbent and improve the cycle's financial viability. This review provides a concise overview of the future directions and outlook in the framework of adsorbent application for industrial wastewater treatment.

Prediction of Incident Heart Failure in CKD: The CRIC Study

Introduction

Heart failure (HF) is common in chronic kidney disease (CKD); identifying patients with CKD at high risk for HF may guide clinical care. We assessed the prognostic value of cardiac biomarkers and echocardiographic variables for 10-year HF prediction compared with a published clinical HF prediction equation in a cohort of participants with CKD.

Methods

We studied 2147 Chronic Renal Insufficiency Cohort (CRIC) participants without prior HF with complete clinical, cardiac biomarker (N-terminal brain natriuretic peptide [NT-proBNP] and high sensitivity troponin-T [hsTnT]), and echocardiographic data (left ventricular mass [LVM] and left ventricular ejection fraction [LVEF] data). We compared the discrimination of the 11-variable Atherosclerosis Risk in Communities (ARIC) HF prediction equation with LVM, LVEF, hsTnT, and NT-proBNP to predict 10-year risk of hospitalization for HF using a Fine and Gray modeling approach. We separately evaluated prediction of HF with preserved and reduced LVEF (LVEF ≥50% and <50%, respectively). We assessed discrimination with internally valid C-indices using 10-fold cross-validation.

Results

Participants' mean (SD) age was 59 (11) years, 53% were men, 43% were Black, and mean (SD) estimated glomerular filtration rate (eGFR) was 44 (16) ml/min per 1.73 m2. A total of 324 incident HF hospitalizations occurred during median (interquartile range) 10.0 (5.7-10.0) years of follow-up. The ARIC HF model with clinical variables had a C-index of 0.68. Echocardiographic variables predicted HF (C-index 0.70) comparably to the published ARIC HF model, while NT-proBNP and hsTnT together (C-index 0.73) had significantly better discrimination (P = 0.004). A model including cardiac biomarkers, echocardiographic variables, and clinical variables had a C-index of 0.77. Discrimination of HF with preserved LVEF was lower than for HF with reduced LVEF for most models.

Conclusion

The ARIC HF prediction model for 10-year HF risk had modest discrimination among adults with CKD. NT-proBNP and hsTnT discriminated better than the ARIC HF model and at least as well as a model with echocardiographic variables. HF clinical prediction models tailored to adults with CKD are needed. Until then, measurement of NT-proBNP and hsTnT may be a low-burden approach to predicting HF in this population, as they offer moderate discrimination.

High-Throughput Metabolomics and Diabetic Kidney Disease Progression: Evidence from the Chronic Renal Insufficiency (CRIC) Study

INTRODUCTION

Metabolomics could offer novel prognostic biomarkers and elucidate mechanisms of diabetic kidney disease (DKD) progression. Via metabolomic analysis of urine samples from 995 CRIC participants with diabetes and state-of-the-art statistical modeling, we aimed to identify metabolites prognostic to DKD progression.

METHODS

Urine samples (N = 995) were assayed for relative metabolite abundance by untargeted flow-injection mass spectrometry, and stringent statistical criteria were used to eliminate noisy compounds, resulting in 698 annotated metabolite ions. Utilizing the 698 metabolites' ion abundance along with clinical data (demographics, blood pressure, HbA1c, eGFR, and albuminuria), we developed univariate and multivariate models for the eGFR slope using penalized (lasso) and random forest models. Final models were tested on time-to-ESKD (end-stage kidney disease) via cross-validated C-statistics. We also conducted pathway enrichment analysis and a targeted analysis of a subset of metabolites.

RESULTS

Six eGFR slope models selected 9-30 variables. In the adjusted ESKD model with highest C-statistic, valine (or betaine) and 3-(4-methyl-3-pentenyl)thiophene were associated (p < 0.05) with 44% and 65% higher hazard of ESKD per doubling of metabolite abundance, respectively. Also, 13 (of 15) prognostic amino acids, including valine and betaine, were confirmed in the targeted analysis. Enrichment analysis revealed pathways implicated in kidney and cardiometabolic disease.

CONCLUSIONS

Using the diverse CRIC sample, a high-throughput untargeted assay, followed by targeted analysis, and rigorous statistical analysis to reduce false discovery, we identified several novel metabolites implicated in DKD progression. If replicated in independent cohorts, our findings could inform risk stratification and treatment strategies for patients with DKD.

Phase I/II trial of enzalutamide and mifepristone, a glucocorticoid receptor antagonist, for metastatic castration-resistant prostate cancer

PURPOSE

Although androgen deprivation therapy (ADT) and androgen receptor signaling inhibitors (ARSI) are effective in metastatic prostate cancer (PC), resistance occurs in most patients. This phase I/II trial assessed the safety, pharmacokinetic impact, and efficacy of the glucocorticoid receptor (GR) antagonist mifepristone (Mif) in combination with enzalutamide (Enz) for castration-resistant PC (CRPC).

PATIENTS AND METHODS

106 patients with CRPC were accrued. Phase I subjects were treated with Enz monotherapy at 160 mg per day for 28 days to allow steady-state accumulation. Patients then entered the dose escalation combination portion of the study. In phase II, patients were randomized 1:1 to either receive Enz alone or Enz plus Mif. The primary endpoint was PSA progression free survival (PFS), with radiographic PFS, and PSA response rate (RR) as key secondary endpoints. Circulating tumor cells were collected before randomization for exploratory translational biomarker studies.

RESULTS

We determined a 25% dose reduction in Enz, when added to Mif resulted in equivalent drug levels compared to full dose Enz and was well tolerated. However, the addition of Mif to Enz following a 12-week Enz lead-in did not delay time to PSA, radiographic or clinical PFS. The trial was terminated early due to futility.

CONCLUSION

This is the first prospective trial of dual AR-GR antagonism in CRPC. Enz combined with Mif was safe and well tolerated but did not meet its primary endpoint. The development of more specific GR antagonists combined with AR antagonists, potentially studied in an earlier disease state, should be explored.

Care Coordination: A Concept Analysis

ABSTRACT

Care coordination is both a well-known concept discussed in a wide range of multidisciplinary health care literature and a familiar nursing role in clinical practice; however, the definition of care coordination lacks role clarity across disciplines and within the nursing profession. Despite variations, defining factors of care coordination practice exist; however, role ambiguity limits the effective implementation of evidence-based care coordination in practice and policy. Following Walker and Avant's eight-step concept analysis method, we aim to further clarify care coordination as a concept and practice role and examine the value that nursing brings to its implementation.

Transgender and Gender Diverse Nursing Care

This column is designed to help new nurses in their first year at the bedside-a time of insecurity, growth, and constant challenges-and to offer advice as they learn what it means to be a nurse. Because content on the care of patients who are transgender and gender diverse (TGD) is largely missing from undergraduate nursing curricula, most nurses will learn to care for TGD patients when first working at the bedside. This article offers guidance on providing affirming care to TGD patients, including discussions of gender and pronouns, privacy considerations, and communication and advocacy.

A Framework for Developing Pharmacotherapy for Agitation in Alzheimer's Disease: Recommendations of the ISCTM* Working Group

Dementia is characterized by a significant decline in one of several cognitive domains such as memory, language and executive function, affecting independence and representing a significant deterioration from a previous level of functioning (1). Alzheimer’s Disease (AD) represents the most common form of dementia and contributes up to 70% of the almost 50 million dementia cases worldwide, a number that is projected to double in 20 years (2).