Pharmacologic targeting of coagulation factors XII and XI by monoclonal antibodies reduces thrombosis in nitinol stents under flow

BACKGROUND

Cardiovascular implantable devices, such as vascular stents, are critical for the treatment of cardiovascular diseases. However, their success is dependent on robust and often long-term antithrombotic therapies. Yet, the current standard-of-care therapies often pose significant bleeding risks to patients. Coagulation factor (F)XI and FXII have emerged as potentially safe and efficacious targets to safely reduce pathologic thrombin generation in medical devices.

OBJECTIVES

To study the efficacy of monoclonal antibody-targeting FXII and FXI of the contact pathway in preventing vascular device-related thrombosis.

METHODS

The effects of inhibition of FXII and FXI using function-blocking monoclonal antibodies were examined in a nonhuman primate model of nitinol stent-related thrombosis under arterial and venous flow conditions.

RESULTS

We found that function-blocking antibodies of FXII and FXI reduced markers of stent-induced thrombosis in vitro and ex vivo. However, FXI inhibition resulted in more effective mitigation of thrombosis markers under varied flow conditions.

CONCLUSION

This work provides further support for the translation of contact pathway of coagulation inhibitors for their adjunctive clinical use with cardiovascular devices.

Co-delivery of HIV pre-exposure prophylaxis (PrEP) and HIV testing among publicly insured adolescents and young adults (AYA) receiving medication for opioid use disorder (MOUD)

BACKGROUND

Low rates of HIV pre-exposure prophylaxis (PrEP) prescribing contribute to the disproportionate burden of HIV in the United States. Among adolescent and young adults (AYA) with opioid use disorder, HIV testing and PrEP co-prescription rates are poorly characterized.

METHODS

We performed a retrospective analysis involving deidentified data from Philadelphia's Medicaid beneficiaries ages 16-29 years who were prescribed medication for opioid use disorder (MOUD) from 2015 to 2020 and continuously Medicaid-enrolled for ≥6 months prior to that prescription. After identifying the presence of a qualifying diagnosis signifying a PrEP indication, we examined the outcome of appropriate PrEP co-prescriptions and HIV testing using generalized estimating equations (GEE) modeling.

RESULTS

We identified 795 AYA Medicaid beneficiaries with 1269 qualified treatment episodes. We calculated a PrEP prescribing rate of 29.47 per 1000 person-years among AYA receiving MOUD. The HIV testing rate was 63.47 per 1000 person-years among AYA receiving MOUD. GEE modeling revealed that individuals receiving methadone were more likely (aOR=2.62, 95% CI=1.06-6.49) to receive HIV testing within 6 months after a PrEP-qualifying diagnosis compared to those receiving other MOUD medications. Those who only saw outpatient behavioral health providers were less likely (aOR=0.48, 95% CI=0.24-0.99) to have received an HIV test within 6 months after the PrEP-qualifying diagnosis compared to those receiving inpatient behavioral health services.

CONCLUSIONS

Co-prescription of PrEP and HIV testing among AYA receiving MOUD was rare in this large urban publicly insured population. Interventions are needed to increase HIV prevention services for this key population of AYA at risk for HIV infection.

Low respiratory quotient correlates with high mortality in patients undergoing mechanical ventilation

OBJECTIVE

Oxygen consumption (VO2), carbon dioxide generation (VCO2), and respiratory quotient (RQ), which is the ratio of VO2 to VCO2, are critical indicators of human metabolism. To seek a link between the patient's metabolism and pathophysiology of critical illness, we investigated the correlation of these values with mortality in critical care patients.

METHODS

This was a prospective, observational study conducted at a suburban, quaternary care teaching hospital. Age 18 years or older healthy volunteers and patients who underwent mechanical ventilation were enrolled. A high-fidelity automation device, which accuracy is equivalent to the gold standard Douglas Bag technique, was used to measure VO2, VCO2, and RQ at a wide range of fraction of inspired oxygen (FIO2).

RESULTS

We included a total of 21 subjects including 8 post-cardiothoracic surgery patients, 7 intensive care patients, 3 patients from the emergency room, and 3 healthy volunteers. This study included 10 critical care patients, whose metabolic measurements were performed in the ER and ICU, and 6 died. VO2, VCO2, and RQ of survivors were 282 +/- 95 mL/min, 202 +/- 81 mL/min, and 0.70 +/- 0.10, and those of non-survivors were 240 +/- 87 mL/min, 140 +/- 66 mL/min, and 0.57 +/- 0.08 (p = 0.34, p = 0.10, and p < 0.01), respectively. The difference of RQ was statistically significant (p < 0.01) and it remained significant when the subjects with FIO2 < 0.5 were excluded (p < 0.05).

CONCLUSIONS

Low RQ correlated with high mortality, which may potentially indicate a decompensation of the oxygen metabolism in critically ill patients.

Can the Reboot coaching programme support critical care nurses in coping with stressful clinical events? A mixed-methods evaluation assessing resilience, burnout, depression and turnover intentions

BACKGROUND

Critical care nurses (CCNs) are routinely exposed to highly stressful situations, and at high-risk of suffering from work-related stress and developing burnout. Thus, supporting CCN wellbeing is crucial. One approach for delivering this support is by preparing CCNs for situations they may encounter, drawing on evidence-based techniques to strengthen psychological coping strategies. The current study tailored a Resilience-boosting psychological coaching programme [Reboot] to CCNs. Other healthcare staff receiving Reboot have reported improvements in confidence in coping with stressful clinical events and increased psychological resilience. The current study tailored Reboot for online, remote delivery to CCNs (as it had not previously been delivered to nurses, or in remote format), to (1) assess the feasibility of delivering Reboot remotely, and to (2) provide a preliminary assessment of whether Reboot could increase resilience, confidence in coping with adverse events and burnout.

METHODS

A single-arm mixed-methods (questionnaires, interviews) before-after feasibility study design was used. Feasibility was measured via demand, recruitment, and retention (recruitment goal: 80 CCNs, retention goal: 70% of recruited CCNs). Potential efficacy was measured via questionnaires at five timepoints; measures included confidence in coping with adverse events (Confidence scale), Resilience (Brief Resilience Scale), depression (PHQ-9) and burnout (Oldenburg-Burnout-Inventory). Intention to leave (current role, nursing more generally) was measured post-intervention. Interviews were analysed using Reflexive Thematic Analysis.

RESULTS

Results suggest that delivering Reboot remotely is feasible and acceptable. Seventy-seven nurses were recruited, 81% of whom completed the 8-week intervention. Thus, the retention rate was over 10% higher than the target. Regarding preliminary efficacy, follow-up measures showed significant increases in resilience, confidence in coping with adverse events and reductions in depression, burnout, and intention to leave. Qualitative analysis suggested that CCNs found the psychological techniques helpful and particularly valued practical exercises that could be translated into everyday practice.

CONCLUSION

This study demonstrates the feasibility of remote delivery of Reboot and potential efficacy for CCNs. Results are limited due to the single-arm feasibility design; thus, a larger trial with a control group is needed.

Canadian immigrants' oral health and oral health care providers' cultural competence capacity

Background

Immigrants to Canada count among the socially disadvantaged groups experiencing higher rates of oral disease. Culturally competent oral health care providers (OHCPs) stand to be allies for immigrant oral health. The literature reveals limited knowledge of practising OHCPs' cultural competency, and little synthesis of the topic has been completed. A scoping review is warranted to identify and map current knowledge of OHCPs' understanding of culturally competent care along with barriers and facilitators to developing capacity.

Methods

This study was conducted between December 2022 and April 2023 using Arksey and O'Malley's 5-step framework and PRISMA-ScR checklist. Four databases were searched using keywords related to 4 themes: population, provider, oral health, and cultural competence. Peer-reviewed articles published in English in the last 10 years were included.

Results

Search results yielded 74 articles. Title and abstract review was completed and an author-developed critical appraisal tool was applied. Forty-six (46) articles were subject to full-text review and 14 met eligibility criteria: 7 qualitative and 7 quantitative. Six barriers and six facilitators at individual and systemic levels were identified, affecting oral care for immigrants and providers' ability to work cross-culturally.

Discussion

Lack of cultural or linguistically appropriate resources, guidance, and structural supports were identified as contributing to low utilization of services and to lack of familiarity between providers and immigrants.

Conclusion

OHCPs' cultural competency development is required to improve oral health care access and outcomes for diverse populations. Further research is warranted to identify factors impeding OHCPs' capacity to provide culturally sensitive care. Intentional policy development and knowledge mobilization are needed.

Elimination of 15N-thymidine after oral administration in human infants

BACKGROUND

We have developed a new clinical research approach for the quantification of cellular proliferation in human infants to address unanswered questions about tissue renewal and regeneration. The approach consists of oral 15N-thymidine administration to label cells in S-phase, followed by Multi-isotope Imaging Mass Spectrometry for detection of the incorporated label in cell nuclei. To establish the approach, we performed an observational study to examine uptake and elimination of 15N-thymidine. We compared at-home label administration with in-hospital administration in infants with tetralogy of Fallot, a form of congenital heart disease, and infants with heart failure.

METHODS

We examined urine samples from 18 infants who received 15N-thymidine (50 mg/kg body weight) by mouth for five consecutive days. We used Isotope Ratio Mass Spectrometry to determine enrichment of 15N relative to 14N (%) in urine.

RESULTS/FINDINGS

15N-thymidine dose administration produced periodic rises of 15N enrichment in urine. Infants with tetralogy of Fallot had a 3.2-fold increase and infants with heart failure had a 4.3-fold increase in mean peak 15N enrichment over baseline. The mean 15N enrichment was not statistically different between the two patient populations (p = 0.103). The time to peak 15N enrichment in tetralogy of Fallot infants was 6.3 ± 1 hr and in infants with heart failure 7.5 ± 2 hr (mean ± SEM). The duration of significant 15N enrichment after a dose was 18.5 ± 1.7 hr in tetralogy of Fallot and in heart failure 18.2 ± 1.8 hr (mean ± SEM). The time to peak enrichment and duration of enrichment were also not statistically different (p = 0.617 and p = 0.887).

CONCLUSIONS

The presented results support two conclusions of significance for future applications: (1) Demonstration that 15N-thymidine label administration at home is equivalent to in-hospital administration. (2) Two different types of heart disease show no differences in 15N-thymidine absorption and elimination. This enables the comparative analysis of cellular proliferation between different types of heart disease.

Addressing gaps in healthcare provider knowledge regarding germline testing for prostate cancer through development and testing of a virtual genetics board

BACKGROUND

Germline testing is important in prostate cancer and evaluation can be complex.

METHODS

We instituted a monthly multi-disciplinary virtual genetics tumor board (7/2021-3/2022). Participants and panelists were surveyed on usefulness and acceptability.

RESULTS

101 participants attended a session, and 77 follow-up surveys were completed. Over 90% participants and 100% panelists endorsed usefulness of the case discussions and usability of the technology. The majority felt it provided new information they will use.

CONCLUSIONS

A multidisciplinary genetics board was successfully developed to address complexity in prostate cancer genetics. The virtual platform may enhance dissemination of expertise where there are regional gaps.

Treatment Response of Gingival Squamous-Cell Carcinoma to Palliative Intent Immunotherapy

The use of PD-1 immune checkpoint inhibitor medications has become a common practice in the treatment of recurrent and metastatic head and neck squamous-cell carcinomas. Success in this setting has led to the investigation of their efficacy in locally advanced cases as a part of first-line therapy. In this report, we detail the treatment response to palliative intent immunotherapy of three geriatric patients with mandibular gingival squamous-cell carcinoma who decided against surgical intervention. Patient #1 was treated with pembrolizumab, a PD-1 inhibitor, and displayed complete clinical and radiologic response of the gingival mass after three months of treatment, which is ongoing at 19 months from initiation. Patients #2 and 3 are each on treatment with single-agent pembrolizumab, with partial response of their tumors, minimal side effects, and ongoing response at 9 and 5 months of treatment, respectively. Durable clinical treatment response to palliative immunotherapy, as is evident in this report, warrants further consideration and investigation in the geriatric population. With appropriate patient selection, surgery may be avoided and allow patients to prioritize quality of life over curative intent surgery.

A Randomised Clinical Feasibility Trial of a Breast Immobilisation Device: The SuPPORT 4 All Bra

AIMS

Despite the breast being a mobile organ, there is currently no standard suitable immobilisation device to optimise radiotherapy for women with larger breasts treated after a wide local excision. The SuPPORT 4 All (S4A) bra was co-designed with patients and radiotherapy professionals. The purpose of this study was to test the feasibility of using the S4A bra in the existing breast cancer radiotherapy pathway.

MATERIALS AND METHODS

A randomised feasibility trial was conducted in a single institution; the primary feasibility endpoint was the recruitment of 50 participants. Efficacy endpoints were also tested, including assessment of skin reactions, dose to organs at risk and patient comfort. Fifty women were randomised to receive either standard radiotherapy with no immobilisation (control) or radiotherapy with the S4A bra (intervention). A separate planning study was undertaken on the cases randomised to receive the S4A bra. Participants in the intervention arm (S4A bra) underwent two planning computed tomography scans, one with the bra on and one without the bra; allowing direct comparison of organs at risk data for S4A bra versus no bra.

RESULTS

All women who started radiotherapy wearing the S4A bra completed treatment with the bra; patient comfort did not change across the 3 weeks of treatment. Positional accuracy using the bra was comparable with existing published accuracy for methods without immobilisation. The mean ipsilateral lung doses showed some improvement when positioning with the S4A bra was compared with the no bra set-up (3.72 Gy versus 4.85 Gy for right-sided cases, 3.23 Gy versus 3.62 Gy for left-sided cases).

CONCLUSIONS

The S4A bra is feasible to use in the radiotherapy pathway with good patient adherence. The S4A bra has potential to reduce dose to organs at risk (specifically ipsilateral lung dose) while maintaining good breast tissue coverage, and improved patient dignity, warranting further investigation on a larger scale.

Development and validation of a novel score to predict brain death after out-of-hospital cardiac arrest

BACKGROUND AND OBJECTIVES

Brain death (BD) occurs in 9-24% of successfully resuscitated out-of-hospital cardiac arrests (OHCA). To predict BD after OHCA, we developed a novel brain death risk (BDR) score.

METHODS

We identified independent predictors of BD after OHCA in a retrospective, single academic center cohort between 2011 and 2021. The BDR score ranges from 0 to 7 points and includes: non-shockable rhythm (1 point), drug overdose as etiology of arrest (1 point), evidence of grey-white differentiation loss or sulcal effacement on head computed tomography (CT) radiology report within 24 hours of arrest (2 points), Full-Outline-Of-UnResponsiveness (FOUR) score of 0 (2 points), FOUR score 1-5 (1 point), and age <45 years (1 point). We internally validated the BDR score using k-fold cross validation (k = 8) and externally validated the score at an independent academic center. The main outcome was BD.

RESULTS

The development cohort included 362OHCA patients, of whom 18% (N = 58) experienced BD. Internal validation provided an area under the receiving operator characteristic curve (AUC) (95% CI) of 0.931 (0.905-0.957). In the validation cohort, 19.8% (N = 17) experienced BD. The AUC (95% CI) was 0.849 (0.765-0.933). In both cohorts, a BDR score >4 was the optimal cut off (sensitivity 0.903 and 0.882, specificity 0.830 and 0.652, in the development and validation cohorts respectively).

DISCUSSION

The BDR score identifies those at highest risk for BD after OHCA. Our data suggest that a BDR score >4 is the optimal cut off.

Continuous and repeat metabolic measurements compared between post-cardiothoracic surgery and critical care patients

OBJECTIVE

Using a system, which accuracy is equivalent to the gold standard Douglas Bag (DB) technique for measuring oxygen consumption (VO2), carbon dioxide generation (VCO2), and respiratory quotient (RQ), we aimed to continuously measure these metabolic indicators and compare the values between post-cardiothoracic surgery and critical care patients.

METHODS

This was a prospective, observational study conducted at a suburban, quaternary care teaching hospital. Age 18 years or older patients who underwent mechanical ventilation were enrolled.

RESULTS

We included 4 post-surgery and 6 critical care patients. Of those, 3 critical care patients died. The longest measurement reached to 12 h and 15 min and 50 cycles of repeat measurements were performed. VO2 of the post-surgery patients were 234 ± 14, 262 ± 27, 212 ± 16, and 192 ± 20 mL/min, and those of critical care patients were 122 ± 20, 189 ± 9, 191 ± 7, 191 ± 24, 212 ± 12, and 135 ± 21 mL/min, respectively. The value of VO2 was more variable in the post-surgery patients and the range of each patient was 44, 126, 71, and 67, respectively. SOFA scores were higher in non-survivors and there were negative correlations of RQ with SOFA.

CONCLUSIONS

We developed an accurate system that enables continuous and repeat measurements of VO2, VCO2, and RQ. Critical care patients may have less activity in metabolism represented by less variable values of VO2 and VCO2 over time as compared to those of post-cardiothoracic surgery patients. Additionally, an alteration of these values may mean a systemic distinction of the metabolism of critically ill patients.

Influence of Annealing on the Structural, Morphological, Photoluminescence and Visible Absorption Properties of Mg Doped CuO Micro Grains

Narrow band gap oxide materials that harvest visible light have gained considerable attention for numerous visible light mediated applications. In this current work, a typical Mg doped CuO bulk material was prepared by a simple wet chemical method. The prepared material was annealed in three different temperatures viz.; 300 °C, 400 and 500 °C in air atmosphere to tune the optical band gap. XRD studies reveal that the average crystallite size increases with increase in annealing temperature. FESEM images of all the samples show their bulk nature with different grain sizes and morphologies. XPS survey scan spectra exhibit photoelectron emissions of Cu2p, O1s and Mg 1s with binding energies 933.69 eV, 533.41 eV and 1304.2 eV for all the samples and validated the effective incorporation of Mg ions into the CuO lattice. PL spectra reveal the polychromatic UV- visible luminescence bands for all the annealed samples, whereby the PL intensity is found to be decreasing as the annealing temperature increases. Finally, the band gap decreases with annealing temperature and indicates that the sample annealed at 500 °C can be exploited for visible light assisted applications such as solar cells, photocatalysis and photoelectrochemical cell.

Recruiting the Voices of Persons With Intellectual and Developmental Disabilities in Policy Development: Priorities for Health Equity Data

Through focus groups, adults with intellectual and developmental disabilities (IDD) provided their priorities for health equity data, surveys, and information dissemination by U.S. federal agencies. Participants reported privacy concerns about sharing information, need for better data to promote access to quality health care and services, and need for information on social contexts that influence quality of life. Data should include functional limitations, health risks, and priorities for health care, and should support choice and self-determination. Adults with IDD believe parents or support persons do not always share their views, raising concerns about proxy reporting. Surveys and information need to use clear language, visual aids, and provide neutral supports. Information should be shared broadly, including to persons with IDD and families, health care professionals, and policy makers.

Feasibility and Safety of Single-Isocenter/Multi-Lesion (SIML) HyperArc Brain SRT: Clinical Implementation and Early Outcomes

PURPOSE/OBJECTIVE(S)

Patients with multiple brain metastases may not tolerate relatively longer treatment times for traditional stereotactic radiation therapy (SRT) with individual isocenter plans for each lesion due to discomfort or co-morbidities. SRT using a single-isocenter/multi-lesion (SIML) HyperArc volumetric modulated arc therapy (VMAT) plan with flattening filter free (FFF) beam could significantly shorten overall treatment time, and improve patient comfort, compliance, and clinic efficiency. We report early clinical results of treating multiple brain metastases with SIML HyperArc SRT.

MATERIALS/METHODS

Twenty-three patients with multiple brain metastatic tumors (range, 2-9 lesions; total treated lesions, n = 96) were simulated using Encompass support and Q-fix mask, and treated with a highly-conformal SIML VMAT SRT plans via non-coplanar HyperArc geometry. Mean tumor distance to isocenter was 5.3 cm, maximum up to 7 cm. Common prescriptions were 25-30 Gy/5 fractions, 24-27 Gy/3 fractions, and 20 Gy/1 fraction prescribed to each planning target volume (PTV) using 2 mm margin around standard gross tumor volume (GTV) delineated on contrasted enhanced MP-RAGE MRI fusion. Acuros dose calculation for 6MV-FFF beam was used for tissue heterogeneity corrections. Alliance A071801 criteria was used for dose constraints to organs at risk (OAR) and target conformality. Treatment was delivered every other day with CBCT-guidance, adjustments made with 6DOF couch corrections on a medical linear accelerator, and treatment delivery time within 15 minutes. Local control rates were reported, and toxicity profile rated based on CTCAE v5.0 for brain radionecrosis, optic neuropathy, and brainstem dysfunction.

RESULTS

All plans met Alliance A071801 requirements for each tumor coverage, dose to OAR including optic apparatus, brainstem, and spinal cord. Mean GTV and PTV volume were 9.4 cc (range, 0.3-54.8 cc) and 16.13 cc (range, 1.0-80.2 cc). Patient-specific quality assurance results were 98.3% for gamma passing criteria of 2%/2mm. Independent in-house Monte Carlo physics second check agreed with HyperArc plans by ±3.0%. Mean follow up was 6 months (range, 0.0-18.6 months). Of the 23 patients treated, 17 (74%) had post-treatment MRI imaging to assess local control and toxicity. Local control was achieved in 69/73 (95%) of treated and followed lesions. CTCAE grade 2 radionecrosis occurred in 2 patients and were managed with dexamethasone. No CTCAE grade 3+ events of radionecrosis, optic pathway dysfunction, or brainstem toxicity were observed.

CONCLUSION

SIML HyperArc Brain SRT for multiple brain metastases has excellent local control and low toxicity profile in our patients. It can significantly reduce treatment delivery time as compared to traditional multiple-isocenter brain SRT or chronologically separate treatment courses and thus, help to improve patient comfort, compliance, ease of care, and clinic workflow. Longer median follow up of SIML brain SRT on larger patient cohort is warranted.

Genomic evaluation of feed efficiency in US Holstein heifers

There is growing interest in improving feed efficiency traits in dairy cattle. The objectives of this study were to estimate the genetic parameters of residual feed intake (RFI) and its component traits [dry matter intake (DMI), metabolic body weight (MBW), and average daily gain (ADG)] in Holstein heifers, and to develop a system for genomic evaluation for RFI in Holstein dairy calves. The RFI data were collected from 6,563 growing Holstein heifers (initial body weight = 261 ± 52 kg; initial age = 266 ± 42 d) for 70 d, across 182 trials conducted between 2014 and 2022 at the STgenetics Ohio Heifer Center (South Charleston, OH) as part of the EcoFeed program, which aims to improve feed efficiency by genetic selection. The RFI was estimated as the difference between a heifer's actual feed intake and expected feed intake, which was determined by regression of DMI against midpoint MBW, age, and ADG across each trial. A total of 61,283 SNPs were used in genomic analyses. Animals with phenotypes and genotypes were used as training population, and 4 groups of prediction population, each with 2,000 animals, were selected from a pool of Holstein animals with genotypes, based on their relationship with the training population. All traits were analyzed using univariate animal model in DMU version 6 software. Pedigree information and genomic information were used to specify genetic relationships to estimate the variance components and genomic estimated breeding values (GEBV), respectively. Breeding values of the prediction population were estimated by using the 2-step approach: deriving the prediction equation of GEBV from the training population for estimation of GEBV of prediction population with only genotypes. Reliability of breeding values was obtained by approximation based on partitioning a function of the accuracy of training population GEBV and magnitudes of genomic relationships between individuals in the training and prediction population. Heifers had DMI (mean ± SD) of 8.11 ± 1.59 kg over the trial period, with growth rate of 1.08 ± 0.25 kg/d. The heritability estimates (mean ± SE) of RFI, MBW, DMI, and growth rate were 0.24 ± 0.02, 0.23 ± 0.02, 0.27 ± 0.02, and 0.19 ± 0.02, respectively. The range of genomic predicted transmitted abilities (gPTA) of the training population (-0.94 to 0.75) was higher compared with the range of gPTA (-0.82 to 0.73) of different groups of prediction population. Average reliability of breeding values from the training population was 58%, and that of prediction population was 39%. The genomic prediction of RFI provides new tools to select for feed efficiency of heifers. Future research should be directed to find the relationship between RFI of heifers and cows, to select individuals based on their lifetime production efficiencies.

Advancing Equity Through Centering Societal Values to Operationalize Racism as a Public Health Crisis: The KKey Values Inequities Model

Background

The past two decades have been marked by increased efforts to advance equity in various disciplines, including social sciences, public health, environmental health, and medicine. In 2020, a national movement of municipalities declared racism a public health crisis. These efforts have coincided and likely shaped a growing sphere of federal and philanthropic funding for health equity, which frequently calls for practical interventions toward reducing and ultimately eliminating disparities. Disparities in health such as maternal mortality, infant mortality, diabetes, cancer, and stroke have been linked to root causes such as racism. Often, root causes are also linked to disparities in other sectors (i.e., finance/wealth attainment, educational attainment, career attainment, and home ownership). In 2021, in a study published in the New England Journal of Medicine, suggested that racist policies were root causes of U.S. racial health inequities. While racism, sexism, and classism, etc., are characterized as root causes, we posit that there is a deeper driver that has yet to be advanced. This presents a disparity-inequity model that maps disparities and inequities to the societal value system, not root causes.

Methods

The KKey Values Inequities Disparities Model described in this article combines a case study of the Flint Water Crisis to explore the historic impact of human devaluation and its role in systemic racism and classism, which ultimately creates and exacerbates inequities that produce disparities in communities. The model integrates the value system and its contribution to societal causes (formerly known as root causes).

Conclusions

A broadly defined values-inequities-disparities model will allow researchers, practitioners, decision makers, lawmakers, and community members to (1) assess the core root of inequities and disparities; (2) identify solutions in the human value domain; (3) design appropriate course corrective programming, interventions, processes, and procedures; and (4) create actions to integrate new systemic procedures and practices in our laws and governance to advance equity.

A novel non-word speech preparation task to increase stuttering frequency in experimental settings for longitudinal research

PURPOSE

The variable and intermittent nature of stuttering makes it difficult to consistently elicit a sufficient number of stuttered trials for longitudinal experimental research. This study tests the efficacy of using non-word pairs that phonetically mimic English words with no associated meaning, to reliably elicit balanced numbers of stuttering and fluent trials over multiple sessions. The study also evaluated the effect of non-word length on stuttering frequency, the consistency of stuttering frequency across sessions, and potential carry-over effects of increased stuttering frequency in the experimental task to conversational and reading speech after the task.

METHODS

Twelve adults who stutter completed multiple sessions (mean of 4.8 sessions) where they were video-recorded during pre-task reading and conversation, followed by an experimental task where they read 400 non-word pairs randomized for each session, and then a post-task reading and conversation sample.

RESULTS

On average, across sessions and participants, non-word pairs consistently yielded a balanced distribution of fluent (60.7%) and stuttered (39.3%) trials over five sessions. Non-word length had a positive effect on stuttering frequency. No carryover effects from experimental to post-task conversation and reading were found.

CONCLUSIONS

Non-word pairs effectively and consistently elicited balanced proportions of stuttered and fluent trials. This approach can be used to gather longitudinal data to better understand the neurophysiological and behavioral correlates of stuttering.

Impact of Head and Neck Cancer Diagnosis and Treatment on Patient-Partner Intimacy

OBJECTIVE

To determine the effects of head and neck squamous cell carcinoma diagnosis and treatment on patient- and partner-perceived intimacy and to understand if a diagnosis of HPV-related head and neck squamous cell carcinoma influences patient-partner intimacy.

STUDY DESIGN

Prospective observational.

SETTING

Single tertiary care center.

METHODS

An investigator-developed questionnaire was used to prospectively survey patients and partners in 2 groups based on human papillomavirus (HPV) status: HPV+ and HPV- at diagnosis (visit 1) and after treatment (visit 2). Surveys were scored on a 60-point scale, and results were categorized as follows: loss of intimacy (0-30), stable relationship (31-41), or improvement in intimacy (42-60). Responses of couples who participated together were assessed for concordance. Responses were considered discordant if patient and partner scores equated to different levels of perceived intimacy. Median patient and partner scores were compared via Mann-Whitney U test, and concordance was assessed with a chi-square test.

RESULTS

Thirty-four patients and 28 partners completed surveys at visit 1 and 28 patients and 15 partners at visit 2. Median scores among patients and partners were similar at the first time point (HPV+, 45 vs 45, P = .64; HPV-, 42.6 vs 40.8, P = .29) and the second (HPV+, 44.5 vs 44, P = .87; HPV-, 40.2 vs 39.6, P = .90). Concordance rates between HPV+ and HPV- couples were 63% vs 44% (P = .43) for the first time point and 89% vs 50% (P = .24) for the second.

CONCLUSION

Patients and partners reported stable or improved intimacy at both time points, and most couples tended to agree on their levels of perceived intimacy. A diagnosis of HPV did not appear to significantly affect intimacy scores.

Deficiency of the Polycomb Protein RYBP and TET Methylcytosine Oxidases Promotes Extensive CpG Island Hypermethylation and Malignant Transformation

Hypermethylation of CpG islands (CGI) is a common feature of cancer cells and predominantly affects Polycomb-associated genomic regions. Elucidating the underlying mechanisms leading to DNA hypermethylation in human cancer could help identify chemoprevention strategies. Here, we evaluated the role of Polycomb complexes and 5-methylcytosine (5mC) oxidases in protecting CGIs from DNA methylation and observed that four genes coding for components of Polycomb repressive complex 1 (PRC1) are downregulated in tumors. Inactivation of RYBP, a key activator of variant PRC1 complexes, in combination with all three 5mC oxidases (TET proteins) in nontumorigenic bronchial epithelial cells led to widespread hypermethylation of Polycomb-marked CGIs affecting almost 4,000 target genes, which closely resembled the DNA hypermethylation landscape observed in human squamous cell lung tumors. The RYBP- and TET-deficient cells showed methylation-associated aberrant regulation of cancer-relevant pathways, including defects in the Hippo tumor suppressor network. Notably, the quadruple knockout cells acquired a transformed phenotype, including anchorage-independent growth and formation of squamous cell carcinomas in mice. This work provides a mechanism promoting hypermethylation of CGIs and shows that such hypermethylation can lead to cell transformation. The breakdown of a two-pronged protection mechanism can be a route towards genome-wide hypermethylation of CGIs in tumors.

SIGNIFICANCE

Dysfunction of the Polycomb component RYBP in combination with loss of 5-methylcytosine oxidases promotes widespread hypermethylation of CpG islands in bronchial cells and induces tumorigenesis, resembling changes seen in human lung tumors.

Self-reported COVID-19 infection, and illness severity associated with a large professional-society meeting of the AAPM in 2022

BACKGROUND

Many in-person conferences were suspended during the initial stages of the COVID-19 pandemic but have recently begun to return to in-person or hybrid formats. However the incidence and severity of COVID-19 infection during conferences, as well as behaviors at meetings associated with infection, are not well known.

PURPOSE

We performed a targeted, systematic survey of self-reported COVID-19 infection and severity rates among in-person attendees and potential attendees of a large national medical conference held in hybrid format during the during the Omicron subvariant wave, to provide guidance for future meeting attendees and organizers on COVID-19 risk.

METHODS

A survey was sent to all members of the American Association of Physicists in Medicine (AAPM) as well as all attendees of the AAPM 2022 Annual Meeting (held July 10th-14th 2022 in Washington DC) with hybrid format) (total n = 10,627). The survey assessed relevant respondent demographics, views of COVID-19 and in-person meetings, COVID-19 infection during the meeting or the following 7 days, and any COVID-19 treatment received. Descriptive statistics and multivariable logistic regression with odds ratios (OR) and 95% confidence intervals (CI) were used for analysis.

RESULTS

The response rate was 13.7% (n = 1464) among the total invitees. Of respondents, 62.9% (n = 921) attended the meeting in person and 37.1% (n = 543) did not. Among in-person meeting attendees, 82.1% (n = 756) attended indoor social events during the meeting including 67.5% (n = 509) who attended a large, AAPM-coordinated social event. Reported COVID-19 infection rates were higher among in-person attendees (15.3%, n = 141) versus those that did not attend in-person (6.1%, n = 33) (p < 0.001). Of those infected, 97.9% (n = 138) recovered entirely at home, with the remaining 2 (1.4%) undergoing emergency room visit without admission, and 1 (unvaccinated) individual (0.7%) reported hospital admission. On multivariable analysis of reported in-person attendee behaviors, only attendance of the large, AAPM-coordinated social event remained significantly associated with COVID-19 infection (OR 2.8, CI 1.8-4.2, p < 0.001). Among in-person attendees, 74.1% (n = 682) agreed that they would feel comfortable attending in-person conferences in the future, 11.8% (n = 109) disagreed, and 14.0% (n = 129) neither agreed nor disagreed.

CONCLUSIONS

Despite higher than previously reported COVID-19 infection rates than prior studies, severity of infection was self-limited with no hospitalizations among vaccinated attendees. In-person attendees showed a willingness to return to large-scale indoor social interaction, with a higher rate of COVID-19 infection noted among those who attended a large conference-affiliated social gathering. Most individuals reported feeling comfortable attending other in-person meetings in the future.

First Dark Matter Search Results from the LUX-ZEPLIN (LZ) Experiment

The LUX-ZEPLIN experiment is a dark matter detector centered on a dual-phase xenon time projection chamber operating at the Sanford Underground Research Facility in Lead, South Dakota, USA. This Letter reports results from LUX-ZEPLIN's first search for weakly interacting massive particles (WIMPs) with an exposure of 60 live days using a fiducial mass of 5.5 t. A profile-likelihood ratio analysis shows the data to be consistent with a background-only hypothesis, setting new limits on spin-independent WIMP-nucleon, spin-dependent WIMP-neutron, and spin-dependent WIMP-proton cross sections for WIMP masses above 9  GeV/c^{2}. The most stringent limit is set for spin-independent scattering at 36  GeV/c^{2}, rejecting cross sections above 9.2×10^{-48}  cm at the 90% confidence level.

Validation of the rCAST Score and Comparison to the PCAC and FOUR Scores for Prognostication after Out-of-Hospital Cardiac Arrest

AIM

Early, accurate outcome prediction after out-of-hospital cardiac arrest (OHCA) is critical for clinical decision-making and resource allocation. We sought to validate the revised post-Cardiac Arrest Syndrome for Therapeutic hypothermia (rCAST) score in a United States cohort and compare its prognostic performance to the Pittsburgh Cardiac Arrest Category (PCAC) and Full Outline of UnResponsiveness (FOUR) scores.

METHODS

This is a single-center, retrospective study of OHCA patients admitted between January 2014-August 2022. Area under the receiver operating curve (AUC) was computed for each score for predicting poor neurologic outcome at discharge and in-hospital mortality. We compared the scores' predictive abilities via Delong's test.

RESULTS

Of 505 OHCA patients with all scores available, the medians [IQR] for rCAST, PCAC, and FOUR scores were 9.5 [6.0, 11.5], 4 [3,4], and 2 [0, 5], respectively. The AUC [95% confidence interval] of the rCAST, PCAC, and FOUR scores for predicting poor neurologic outcome were 0.815 [0.763 - 0.867], 0.753 [0.697 - 0.809], and 0.841 [0.796 - 0.886], respectively. The AUC [95% confidence interval] of the rCAST, PCAC, and FOUR scores for predicting mortality were 0.799 [0.751 - 0.847], 0.723 [0.673 - 0.773], and 0.813 [0.770 - 0.855], respectively. The rCAST score was superior to the PCAC score for predicting mortality (p=0.017). The FOUR score was superior to the PCAC score for predicting poor neurological outcome (p<0.001) and mortality (p<0.001).

CONCLUSION

The rCAST score can reliably predict poor outcome in a United States cohort of OHCA patients regardless of TTM status and outperforms the PCAC score.

Genomic profiling and precision medicine in complex ameloblastoma

BACKGROUND

Ameloblastoma may present a significant treatment challenge in the locally advanced, recurrent and metastatic setting. Comprehensive genomic profiling (CGP) can identify targetable genomic alterations to aid in treatment.

METHODS

Ameloblastoma samples were sequenced using hybrid-capture based sequencing. A systematic literature review was performed to examine outcomes in studies employing targeted treatment in ameloblastoma.

RESULTS

We reviewed 14 cases of Ameloblastoma using CGP. There were six patients with activating BRAF mutations, five with PIK3CA, five with SMO, four with FGFR2, one with EGFR, and one with ROS1. All cases were MSI stable and the median TMB was 2.5 mutations/Mb. A separate literature review of clinical outcomes in ameloblastoma showed a predominance of at least partial response to targeted treatment (7/12 cases).

CONCLUSION

CGP is helpful in identifying specific driver mutations in patients with complex ameloblastoma. Targeted treatment has been employed with success in achieving treatment response.

Evaluation of a training programme for critical incident debrief facilitators

BACKGROUND

Critical incident debriefs are a commonly used occupational health tool for supporting staff after traumatic work incidents. However, there is a dearth of literature evaluating training programmes for debrief facilitators.

AIMS

To evaluate a 5-day training programme to equip healthcare, social care and voluntary, community and social enterprise sector staff to act as post-incident peer supporters and debrief facilitators.

METHODS

A mixed-methods, single-arm, before-and-after study. Data were collected at baseline and post-training. The quantitative outcome measure was 'Confidence'; the sum of two items measuring confidence in (i) supporting peers after critical incidents and (ii) facilitating post-incident structured team discussions. At post-training, quantitative and qualitative feedback regarding experiences and perceptions of the training was also gathered.

RESULTS

We recruited 45 participants between October 2021 and January 2022. Confidence in supporting peers following incidents and facilitating post-incident structured team discussions increased significantly following the training, t(35) = -6.77, P < 0.001. A majority of participants reported they would do things differently because of the training and that they found the training relevant, useful and engaging. Summative content analysis of qualitative feedback indicated that participants (i) believed the role plays were an important learning tool and (ii) thought it was important that the trainer was engaging. Some participants would have preferred in-person delivery.

CONCLUSIONS

Participants valued training in post-incident peer support and debriefing skills. Organizations implementing post-incident support pathways could usefully include this training and ensure optimal uptake and engagement by (i) providing in-person and online delivery options and (ii) including role play as a learning technique.

Cellular mechanisms and effects of IL-4 receptor blockade in experimental conjunctivitis evoked by skin inflammation

Ocular surface diseases, including conjunctivitis, are recognized as common comorbidities in atopic dermatitis (AD) and occur at an increased frequency in patients with AD treated with biologics targeting IL-4 receptor α (IL-4Rα) or IL-13. However, the inflammatory mechanisms underlying this pathology are unknown. Here, we developed a potentially novel mouse model of skin inflammation-evoked conjunctivitis and showed that it is dependent on CD4+ T cells and basophils. Blockade of IL-4Rα partially attenuated conjunctivitis development, downregulated basophil activation, and led to a reduction in expression of genes related to type 2 cytokine responses. Together, these data suggest that an IL-4Rα/basophil axis plays a role in the development of murine allergic conjunctivitis. Interestingly, we found a significant augmentation of a number of genes that encode tear proteins and enzymes in anti-IL-4Rα-treated mice, and it may underlie the partial efficacy in this model and may represent candidate mediators of the increased frequency of conjunctivitis following dupilumab in patients with AD.

TRIM28 secures skeletal stem cell fate during skeletogenesis by silencing neural gene expression and repressing GREM1/AKT/mTOR signaling axis

Long bones are generated by mesoderm-derived skeletal progenitor/stem cells (SSCs) through endochondral ossification, a process of sequential chondrogenic and osteogenic differentiation tightly controlled by the synergy between intrinsic and microenvironment cues. Here, we report that loss of TRIM28, a transcriptional corepressor, in mesoderm-derived cells expands the SSC pool, weakens SSC osteochondrogenic potential, and endows SSCs with properties of ectoderm-derived neural crest cells (NCCs), leading to severe defects of skeletogenesis. TRIM28 preferentially enhances H3K9 trimethylation and DNA methylation on chromatin regions more accessible in NCCs; loss of this silencing upregulates neural gene expression and enhances neurogenic potential. Moreover, TRIM28 loss causes hyperexpression of GREM1, which is an extracellular signaling factor promoting SSC self-renewal and SSC neurogenic potential by activating AKT/mTORC1 signaling. Our results suggest that TRIM28-mediated chromatin silencing establishes a barrier for maintaining the SSC lineage trajectory and preventing a transition to ectodermal fate by regulating both intrinsic and microenvironment cues.

Bloodstream infections in neonates with central venous catheters in three tertiary neonatal intensive care units in Pune, India

BACKGROUND

Neonates admitted to the neonatal intensive care unit (NICU) are at risk for healthcare-associated infections, including central line-associated bloodstream infections. We aimed to characterize the epidemiology of bloodstream infections among neonates with central venous catheters admitted to three Indian NICUs.

METHODS

We conducted a prospective cohort study in three tertiary NICUs, from May 1, 2017 until July 31, 2019. All neonates admitted to the NICU were enrolled and followed until discharge, transfer, or death. Cases were defined as positive blood cultures in neonates with a central venous catheter in place for greater than 2 days or within 2 days of catheter removal.

RESULTS

During the study period, 140 bloodstream infections were identified in 131 neonates with a central venous catheter. The bloodstream infection rate was 11.9 per 1000 central line-days. Gram-negative organisms predominated, with 38.6% of cases caused by Klebsiella spp. and 14.9% by Acinetobacter spp. Antimicrobial resistance was prevalent among Gram-negative isolates, with 86.9% resistant to third- or fourth-generation cephalosporins, 63.1% to aminoglycosides, 61.9% to fluoroquinolones, and 42.0% to carbapenems. Mortality and length of stay were greater in neonates with bloodstream infection than in neonates without bloodstream infection (unadjusted analysis, p < 0.001).

CONCLUSIONS

We report a high bloodstream infection rate among neonates with central venous catheters admitted to three tertiary care NICUs in India. Action to improve infection prevention and control practices in the NICU is needed to reduce the morbidity and mortality associated with BSI in this high-risk population.

Circle Damage Sequencing for Whole-Genome Analysis of DNA Damage

There are many sources of endogenous and exogenous DNA damage. Damaged bases represent a threat to genome integrity and may interfere with normal cellular processes such as replication and transcription. To understand the specificity and biological consequences of DNA damage, it is essential to employ methods that are sensitive enough to detect damaged DNA bases at the level of single nucleotide resolution and genome-wide. Here we describe in detail a method we developed for this purpose, circle damage sequencing (CD-seq). This method is based on the circularization of genomic DNA that contains damaged bases and conversion of the damaged sites into double-strand breaks using specific DNA repair enzymes. Library sequencing of the opened circles yields the precise positions of the DNA lesions that are present. CD-seq can be adopted to various types of DNA damage as long as a specific cleavage scheme can be designed.

Digital Pathology, A Cognitively Efficient Teaching Strategy: Current Application and a Glimpse into Future

Introduction/Objective

If pathology education is to be efficacious, it must embrace the ramifications of cognitive load of the learners, to optimize the capacity of the working memory. When undergraduate students commence their learning of pathology, they encounter a heap of new data and classifications. Simplifying these intricate systems into assimilable subschemas and items is key for effective transfer of knowledge. The minimization of the profundity of intrinsic cognitive load is essential, considering that its impact on pathology beginners is often left unaccounted, both in active learning as well as in traditional methods of instruction. In today’s digital generation, digital pathology plays a key role by intertwining disease morphology with clinical presentation and fortifying its pathophysiologic basis. We designed a teaching methodology utilizing digital pathology to evaluate its effect on cognitive load.

Methods/Case Report

Active learning was implemented online using digital pathology, molecular pathology, and laboratory data in case-based setting with question-answer sessions. In small groups, students were encouraged to analyze digital pathology slides with the help of annotations and identify areas of histopathological significance. They utilized this information further to make an accurate diagnosis and answer corresponding questions, with access to answers available later, complemented with algorithms and concept maps. A 14-item structured questionnaire was delivered afterwards to evaluate the efficacy and popularity of the exercise.

Results (if a Case Study enter NA)

End-of-term examination results showed that learners developed higher-order comprehension skills along with a greater potential in interpreting histopathological data towards solving case studies. Feedback revealed a higher degree of overall satisfaction and increased ability to retain information.

Conclusion

Digital transformation of pathology education provides the kind of framework where learning happens naturally - developing in small boosts of progress until expertise is achieved, and students appreciate the value of the ‘learned thing’ along with the real utility of that knowledge. The innovative approach utilizing digitization and integration offers the opportunity of decrement in intrinsic cognitive load by invoking students to build better, reliable, long-lasting, supportable and inclusive schemata while correlating the relevant incoming information with previously stabilized knowledge and consolidating the entirety of understanding.

Neurobehavioral phenotype of Kabuki syndrome: Anxiety is a common feature

Kabuki syndrome (KS) is a Mendelian Disorder of the Epigenetic Machinery (MDEM) caused by loss of function variants in either of two genes involved in the regulation of histone methylation, KMT2D (34–76%) or KDM6A (9–13%). Previously, representative neurobehavioral deficits of KS were recapitulated in a mouse model, emphasizing the role of KMT2D in brain development, specifically in ongoing hippocampal neurogenesis in the granule cell layer of the dentate gyrus. Interestingly, anxiety, a phenotype that has a known association with decreased hippocampal neurogenesis, has been anecdotally reported in individuals with KS. In this study, anxiety and behavior were assessed in a cohort of 60 individuals with molecularly confirmed KS and 25 unaffected biological siblings, via questionnaires (SCARED/GAS-ID and CBCL/ABCL). Participant age ranged from 4 to 43 years old, with 88.3% of participants having a pathogenic variant in KMT2D, and the rest having variants in KDM6A. In addition, data was collected on adaptive function and positive affect/quality of life in participants with KS using appropriate online surveys including ABAS-III and PROMIS Positive Affect. Survey scores were compared within the KS participants across age groups and between KS participants and their unaffected siblings. We found that children with KS have significantly higher anxiety scores and total behavior problem scores than their unaffected siblings (p = 0.0225, p < 0.0001). Moreover, a large proportion of affected individuals (22.2% of children and 60.0% of adults) surpassed the established threshold for anxiety; this may even be an underestimate given many patients are already treated for anxiety. In this sample, anxiety levels did not correlate with level of cognitive or adaptive function in any KS participants, but negatively correlated with positive affect in children with KS (p = 0.0005). These findings indicate that anxiety is a common neurobehavioral feature of KS. Providers should therefore carefully screen individuals with KS for anxiety as well as other behavioral issues in order to allow for prompt intervention. Neurobehavioral anxiety measures may also prove to be important outcome measures for clinical trials in KS.

Pandemic intake questionnaire to improve quality, effectiveness, and efficiency of outpatient neurologic and developmental care at the Kennedy Krieger institute during the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic uniquely affects patients with neurologic and developmental disabilities at the Kennedy Krieger Institute. These patients are at increased risk of co-morbidities, increasing their risk of contracting COVID-19. Disruptions in their home and school routines, and restrictions accessing crucial healthcare services has had a significant impact.

METHODS

A Pandemic Intake questionnaire regarding COVID-19 related medical concerns of guardians of patients was distributed using Qualtrics. Data from May-December 2020 were merged with demographic information of patients from 10 clinics (Center for Autism and Related Disorders (CARD), Neurology, Epigenetics, Neurogenetics, Center for Development and Learning (CDL) Sickle Cell, Spinal Cord, Sturge-Weber syndrome (SWS), Tourette's, and Metabolism). A provider feedback survey was distributed to program directors to assess the effectiveness of this intervention.

RESULTS

Analysis included responses from 1643 guardians of pediatric patients (mean age 9.5 years, range 0-21.6 years). Guardians of patients in more medically complicated clinics reported perceived increased risk of COVID-19 (p < 0.001) and inability to obtain therapies (p < 0.001) and surgeries (p < 0.001). Guardian responses from CARD had increased reports of worsening behavior (p = 0.01). Providers increased availability of in-person and virtual therapies and visits and made referrals for additional care to address this. In a survey of medical providers, five out of six program directors who received the responses to this survey found this questionnaire helpful in caring for their patients.

CONCLUSION

This quality improvement project successfully implemented a pre-visit questionnaire to quickly assess areas of impact of COVID-19 on patients with neurodevelopmental disorders. During the pandemic, results identified several major areas of impact, including patient populations at increased risk for behavioral changes, sleep and/or disruptions of medical care. Most program directors reported improved patient care as a result.

Sleep disturbance is a common feature of Kabuki syndrome

Kabuki syndrome (KS) is a rare epigenetic disorder caused by heterozygous loss of function variants in either KMT2D (90%) or KDM6A (10%), both involved in regulation of histone methylation. While sleep disturbance in other Mendelian disorders of the epigenetic machinery has been reported, no study has been conducted on sleep in KS. This study assessed sleep in 59 participants with KS using a validated sleep questionnaire. Participants ranged in age from 4 to 43 years old with 86% of participants having a pathogenic variant in KMT2D. In addition, data on adaptive function, behavior, anxiety, and quality of life were collected using their respective questionnaires. Some form of sleep issue was present in 71% of participants, with night-waking, daytime sleepiness, and sleep onset delay being the most prevalent. Sleep dysfunction was positively correlated with maladaptive behaviors, anxiety levels, and decreasing quality of life. Sleep issues were not correlated with adaptive function. This study establishes sleep disturbance as a common feature of KS. Quantitative sleep measures may be a useful outcome measure for clinical trials in KS. Further, clinicians caring for those with KS should consider sleep dysfunction as an important feature that impacts overall health and well being in these patients.

CD8+ and FoxP3+ T-Cell Cellular Density and Spatial Distribution After Programmed Death-Ligand 1 Check Point Inhibition

OBJECTIVES

To analyze CD8+ and FoxP3+ T-cell cellular density (CD) and intercellular distances (ID) in head and neck squamous cell carcinoma (HNSCC) samples from a neoadjuvant trial of durvalumab +/- metformin.

METHODS

Paired pre- and post-treatment primary HNSCC tumor samples were stained for CD8+ and FoxP3+. Digital image analysis was used to determine estimated mean CD8+ and FoxP3+ CDs and CD8+-FoxP3+ IDs in the leading tumor edge (LTE) and tumor adjacent stroma (TAS) stratified by treatment arm, human papillomavirus (HPV) status, and pathologic treatment response. A subset of samples was characterized for T-cell related signatures using digital spatial genomic profiling.

RESULTS

Post-treatment analysis revealed a significant decrease in FoxP3+ CD and an increase in CD8+ CDs in the TAS between patients receiving durvalumab and metformin versus durvlaumab alone. Both treatment arms demonstrated significant post-treatment increases in ID. Although HPV+ and HPV- had similar immune cell CDs in the tumor microenvironment, HPV+ pre-treatment samples had 1.60 times greater ID compared with HPV- samples, trending toward significance (p = 0.05). At baseline, pathologic responders demonstrated a 1.16-fold greater CD8+ CDs in the LTE (p = 0.045) and 2.28-fold greater ID (p = 0.001) than non-responders. Digital spatial profiling revealed upregulation of FoxP3+ and cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4) in the TAS (p = 0.006, p = 0.026) in samples from pathologic responders.

CONCLUSIONS

Analysis of CD8+ and FoxP3+ detected population differences according to HPV status, pathologic response, and treatment. Greater CD8+-FoxP3+ ID was associated with pathologic response. CD8+ and FoxP3+ T-cell distributions may be predictive of response to immune checkpoint inhibition.

CLINICALTRIALS

gov (Identifier NCT03618654).

LEVEL OF EVIDENCE

Level 3 Laryngoscope, 2022.

Facilitators and barriers to Children's Advocacy Center-based multidisciplinary teamwork

BACKGROUND

Children's Advocacy Centers (CACs) use a multidisciplinary team (MDT) approach to initiate, coordinate, and provide essential multisector services for children and families who experience child abuse. Despite rapid dissemination of the CAC model across the world, little is known about characteristics associated with CAC-based teamwork.

OBJECTIVE

Given that teamwork characteristics may impact the outcomes of child and families who interact with CACs, the purpose of this qualitative study was to explore experiences, facilitators, and barriers to CAC-based multidisciplinary teamwork.

PARTICIPANTS, SETTING, & METHODS

We conducted semi-structured interviews with members of a MDT at a Midwestern CAC.

RESULTS

Findings suggest that MDT teamwork was fostered by clear communication, responsiveness, commitment, openness, and appropriate resources whereas MDT teamwork was hindered by role confusion, conflicting perspectives, poor communication, low staffing, complex politics, and structural barriers.

CONCLUSIONS

Characteristics of CAC-based teamwork may vary from the teamwork of other types of child protection teams. Interventions that enhance CAC-based teamwork may optimize the function of CAC MDTs and improve outcomes for children and families who engage with CACs.

Environmental photochemistry by cobalt doped magnesium ferrites: UV light assisted degradation of anionic azo and cationic thiazine dyes

In the current study, cobalt magnesium ferrites (Mg_0.8-xCo_xFe₂O₄ for x values 0.2, 0.4 and 0.6) nanoparticles are prepared by combustion method. The morphology, optical, structural, photocatalytic, compositional and vibrational properties of Mg_0.8-xCo_xFe₂O₄ by the influence of cobalt doping is investigated. Fourier Transform Infrared (FTIR) Spectroscopy and X-ray diffraction (XRD) confirms the formation of spinel cubic phase of the prepared ferrites samples. The optical band gap energy shows a strong effect on crystallite size and increases from 4.2 to 4.4 eV as the concentration of cobalt gets increased. TEM images of Mg_0.8-xCo_xFe₂O₄ clearly reveal spherical nanoparticles with decreasing particle size which ranges from 16 to 10 nm. EDAX spectrum confirms the existence of Fe, Co, Mg and oxygen. The photocatalytic studies of Mg_0.8-xCo_xFe₂O₄ are performed for anionic and cationic dyes. The rate constant values of methylene blue are found as 0.017/min, 0.019/min and 0.022/min for Mg_0.8-xCo_xFe₂O₄ for x values 0.2, 0.4 and 0.6 respectively. The degradation efficacy of the prepared samples to degrade methylene blue is high (95%) and it indicates that they may be efficient in degrading environmental pollutants and may prove out to be competent photo-catalyst.

Characterizing response to a dynamic stability modeled approach for thumb carpometacarpal joint pain: A retrospective study

STUDY DESIGN

Retrospective case series.

INTRODUCTION

Literature trends indicate that thumb dynamic stabilization may benefit clients with thumb carpometacarpal (CMC) joint pain and arthritis. There is minimal research investigating whether client characteristics predict responsiveness to hand therapy for thumb dynamic stabilization.

PURPOSE OF THE STUDY

1) To investigate how adults with thumb CMC joint pain responded to a hand therapy dynamic stabilization modeled intervention. 2) To determine if various client factors influenced responsiveness and to what extent.

METHODS

An electronic medical record search identified adults treated from August 2009 through December 2015 for thumb CMC joint pain. Radiographs were retrospectively staged. Outcome measures were 1) Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) total disability score and 2) Numerical Pain Rating Scale (NPRS). Paired t-tests were performed to compare pre and post treatment measures. Multivariate analyses were used to investigate predictive factors.

RESULTS

A total of 249 charts were analyzed. Large overall significant effects were noted for disability score (QuickDASH P <.001, X = 12.1, Cohen's d = 0.9). The average improvement of 2.1 (SD = 2.6) points exceeded the minimal clinically important difference (MCID) of 1.7 points on the NPRS pain scale. Significant predictors of QuickDASH Scores were radiographic staging, bilateral hand involvement and initial pain ratings. Significant predictors for change in pain scores (meeting or exceeding the minimal clinically important difference for the NPRS) were bilateral thumb involvement and initial "pain at worst" rating.

CONCLUSION

After completing hand therapy with a dynamic stabilization approach, clients had less pain and disability. Those who had unilateral thumb pain, or those who started with higher pain levels were most likely to have clinically meaningful improvements in pain. Clients in early CMC osteoarthritis (OA) stages responded better than those in later stages, indicating that early referral to therapy is important.

Dynamic stabilization of the painful thumb: A historical and evidence-informed synthesis

STUDY DESIGN

Expert opinion INTRODUCTION: Thumb carpometacarpal joint (CMC) osteoarthritis is a common condition seen in the hand therapy clinic. Prevalence is generally higher in females, and the percentage rises for post-menopausal females. Patients typically present with pain and functional difficulties. Conservative management is recommended before a surgical consult. Evidence is mounting that a dynamic stability modeled approach has a significant effect on pain and improving function.

PURPOSE

The purpose of this paper is two-fold: first, to present the history and development of a dynamic stabilization model for treatment of the patient with thumb CMC osteoarthritis (OA), and second, to provide expert clinical commentary and recommendations for the treatment of thumb CMC OA in light of the best available evidence.

METHODS

Expert clinical commentary is based on an extensive review of relevant literature.

RESULTS

The current literature and expert opinion supports an evidence-informed multimodal intervention: modalities, pain relief techniques, manual release, joint mobilizations as deemed necessary, neuromuscular re-education through proprioceptive exercises, and education in joint protection principles.

CONCLUSION

A rationale for a dynamic stabilization approach is presented. The unique anatomy of the thumb deserves finely tuned care based on high quality research. To advance our knowledge and clinical skills we must not become stagnant, but continue to generate high level evidence. The standard for future thumb CMC OA studies should be well-defined intervention parameters, consistent documentation, and the use of appropriate patient-rated outcome measures.

Abstract 555: Allogeneic Natural Killer cells engineered to express HER2 CAR, Interleukin 15 and TGF beta dominant negative receptor effectively control HER2+ tumors

Despite the success of HER2 targeted therapies in HER2+ breast and gastric cancer, additional therapies are needed to address treatment-resistant metastatic disease. Adoptive immune cell therapy is a promising therapeutic modality given the remarkable clinical responses seen with autologous chimeric antigen receptor (CAR) T cells in hematological malignancies. However, success of cell therapy in solid tumors has been more limited. Three major impediments to the success of adoptive cell therapies in solid tumors are the heterogeneity of antigen expression, the immunosuppressive tumor microenvironment (TME), and the inherent challenges of manufacturing autologous cells and consequent variability of these cell products. Engineered, off-the-shelf, allogeneic Natural Killer (NK) cells provide a solution to these challenges. We describe here CAT-179, a novel engineered CAR-NK cell therapeutic for HER2+ solid tumors. CAT-179 cells express three transgenes: a HER2-directed CAR to effectively eliminate tumor cells, a Transforming Growth Factor (TGF) β dominant negative receptor (DNR) for resistance to TGFβ -mediated immunosuppression in the TME, and Interleukin 15 (IL15) cytokine to enhance NK cell persistence and activity for durable response. High efficiency engineering of the large (~3.7Kb) cargo containing CAR, IL15, and DNR in CAT-179 is enabled by the non-viral TC Buster™ Transposon System. Transposon engineering of CAT-179 results in high and stable expression of CAR (45% CAR at day 7 post gene delivery) without the need for post-engineering selection. CAT-179 demonstrates both CAR-dependent and innate NK receptor-dependent tumor cell killing in vitro, reducing the likelihood of tumor escape through antigen loss. CAT-179 effectively kills in vitro both high HER2-expressing SKOV3 cells as well as lower HER2-expressing HT-29 cells. CAT-179 also demonstrates resistance to TGFβ mediated immunosuppression, as evidenced by 75% reduction in TGFβ -induced phosphorylation of SMAD2 as well as prevention of TGFβ induced downregulation of NK cell activating receptors and restoration of NK cell cytotoxic activity. These data suggest CAT-179 cells will be protected from TGFβ -mediated immune suppression in the TME. Finally, the addition of IL15 in CAT-179 significantly enhances persistence for at least fourteen days in vitro without the need for exogenous cytokines. Moreover, CAT-179 administration to NSG mice showed expansion and persistence of the transferred cell product. CAT-179 addresses key hurdles to allogeneic cell therapy for solid tumors and is a promising new therapeutic approach for HER2 expressing breast, gastric and other tumors.

Citation Format: Celeste Richardson, Finola Moore, Andres Alvarez, Alexia Barandiaran, Luke Barron, Eugene Choi, Tucker Ezell, Charlotte Franco, Bashar Hamza, Jennifer Johnson, Annie Khamhoung, Taeyoon Kyung, Marilyn Marques, Dominic Picarella, Jared Sewell, Alex Storer, Meghan Walsh, Vipin Suri. Allogeneic Natural Killer cells engineered to express HER2 CAR, Interleukin 15 and TGF beta dominant negative receptor effectively control HER2+ tumors [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 555.

Concordance of hydrogen peroxide-induced 8-oxo-guanine patterns with two cancer mutation signatures of upper GI tract tumors

Oxidative DNA damage has been linked to inflammation, cancer, and aging. Here, we have mapped two types of oxidative DNA damage, oxidized guanines produced by hydrogen peroxide and oxidized thymines created by potassium permanganate, at a single-base resolution. 8-Oxo-guanine occurs strictly dependent on the G/C sequence context and shows a pronounced peak at transcription start sites (TSSs). We determined the trinucleotide sequence pattern of guanine oxidation. This pattern shows high similarity to the cancer-associated single-base substitution signatures SBS18 and SBS36. SBS36 is found in colorectal cancers that carry mutations in MUTYH, encoding a repair enzyme that operates on 8-oxo-guanine mispairs. SBS18 is common in inflammation-associated upper gastrointestinal tract tumors including esophageal and gastric adenocarcinomas. Oxidized thymines induced by permanganate occur with a distinct dinucleotide specificity, 5'T-A/C, and are depleted at the TSS. Our data suggest that two cancer mutational signatures, SBS18 and SBS36, are caused by reactive oxygen species.

Burnout syndrome in Nova Scotia dental hygienists during the COVID-19 pandemic: Maslach Burnout Inventory

BACKGROUND

Burnout syndrome is the result of prolonged occupational stress. The syndrome has 3 dimensions: emotional exhaustion (EE), depersonalization (DP), and reduced personal accomplishment (PA). This study aimed to examine the prevalence of the 3 dimensions of burnout in dental hygienists in Nova Scotia, Canada, (N = 745) as they returned to work during the COVID-19 pandemic following a furlough; to explore the effect of burnout during COVID-19 on dental hygienists' professional lives; and to determine the tools and methods that dental hygienists use to overcome burnout.

METHODS

In this cross-sectional study, participants were asked to complete an anonymous survey inclusive of demographic information, employment characteristics, the Maslach Burnout Inventory Human Services Survey for Medical Personnel (MBI-HSS [MP]), and 2 open-ended questions.

RESULTS

The response rate was 34.9% (n = 260). Approximately one-third (36.2%) of respondents met the criteria for burnout. Contributors to burnout were time, providing dental hygiene care, expectations of dentists, physical and mental health, lack of autonomy, and the COVID-19 pandemic. Reported mechanisms to overcome occupational stress centred on work-life balance, social support networks, working in a positive environment, and physical activity.

DISCUSSION

This study took place during the first wave of the COVID-19 pandemic, which may have influenced the rate of burnout among dental hygienists, particularly within the EE domain where scores were twice as high as those reported in pre-COVID-19 studies.

CONCLUSION

Dental hygienists may be at risk for burnout. Recognizing the signs and symptoms of burnout and implementing healthy behaviours may reduce its detrimental effects.

Ibrutinib Inhibits BMX-Dependent Endothelial VCAM-1 Expression In Vitro and Pro-Atherosclerotic Endothelial Activation and Platelet Adhesion In Vivo

Introduction

Inflammatory activation of the vascular endothelium leads to overexpression of adhesion molecules such as vascular cell adhesion molecule-1 (VCAM-1), contributing to the pro-thrombotic state underpinning atherogenesis. While the role of TEC family kinases (TFKs) in mediating inflammatory cell and platelet activation is well defined, the role of TFKs in vascular endothelial activation remains unclear. We investigated the role of TFKs in endothelial cell activation in vitro and in a nonhuman primate model of diet-induced atherosclerosis in vivo.

Methods and Results

In vitro, we found that ibrutinib blocked activation of the TFK member, BMX, by vascular endothelial growth factors (VEGF)-A in human aortic endothelial cells (HAECs). Blockade of BMX activation with ibrutinib or pharmacologically distinct BMX inhibitors eliminated the ability of VEGF-A to stimulate VCAM-1 expression in HAECs. We validated that treatment with ibrutinib inhibited TFK-mediated platelet activation and aggregation in both human and primate samples as measured using flow cytometry and light transmission aggregometry. We utilized contrast-enhanced ultrasound molecular imaging to measure platelet GPIbα and endothelial VCAM-1 expression in atherosclerosis-prone carotid arteries of obese nonhuman primates. We observed that the TFK inhibitor, ibrutinib, inhibited platelet deposition and endothelial cell activation in vivo.

Conclusion

Herein we found that VEGF-A signals through BMX to induce VCAM-1 expression in endothelial cells, and that VCAM-1 expression is sensitive to ibrutinib in vitro and in atherosclerosis-prone carotid arteries in vivo. These findings suggest that TFKs may contribute to the pathogenesis of atherosclerosis and could represent a novel therapeutic target.

Study protocol for the online adaptation and evaluation of the 'Reboot' (Recovery-boosting) coaching programme, to prepare critical care nurses for, and aid recovery after, stressful clinical events

Background

Critical care nurses (CCNs) are routinely exposed to highly stressful events, exacerbated during the COVID-19 pandemic. Supporting resilience and wellbeing of CCNs is therefore crucial to prevent burnout. One approach for delivering this support is by preparing critical care nurses for situations they may encounter, drawing on evidence-based techniques to strengthen relevant psychological coping strategies. As such, the current study seeks to tailor a Resilience-boosting psychological coaching programme [Reboot] for CCNs, based on cognitive behavioural therapy (CBT) principles and the Bi-Dimensional Resilience Framework (BDF), and (1) to assess the feasibility of delivering Reboot via online, remote delivery to CCNs, and (2) to provide a preliminary assessment of whether Reboot could increase resilience and confidence in coping with adverse events.

Methods

Eighty CCNs (n=80) will be recruited to the 8-week Reboot programme, comprised of two group workshops and two individual coaching calls. The study uses a single-arm before-after feasibility study design and will be evaluated with a mixed-methods approach, using online questionnaires (all participants) and telephone interviews (25% of participants). Primary outcomes will be confidence in coping with adverse events (the Confidence scale) and resilience (the Brief Resilience Scale) measured at four time points.

Discussion

Results will determine whether it is feasible to deliver and evaluate a remote version of the Reboot coaching programme to CCNs, and will indicate whether participating in the programme is associated with increases in confidence in coping with adverse events, resilience and wellbeing (as indicated by levels of depression).