Risk Factors and Outcomes Associated with Gaps in Care in Children with Congenital Heart Disease

Adults with congenital heart disease (CHD) benefit from cardiology follow-up at recommended intervals of ≤ 2 years. However, benefit for children is less clear given limited studies and unclear current guidelines. We hypothesize there are identifiable risks for gaps in cardiology follow-up in children with CHD and that gaps in follow-up are associated with differences in healthcare utilization. Our cohort included children < 10 years old with CHD and a healthcare encounter from 2008 to 2013 at one of four North Carolina (NC) hospitals. We assessed associations between cardiology follow-up and demographics, lesion severity, healthcare access, and educational isolation (EI). We compared healthcare utilization based on follow-up. Overall, 60.4% of 6,969 children received cardiology follow-up within 2 years of initial encounter, including 53.1%, 58.1%, and 79.0% of those with valve, shunt, and severe lesions, respectively. Factors associated with gaps in care included increased drive time to a cardiology clinic (Hazard Ratio (HR) 0.92/15-min increase), EI (HR 0.94/0.2-unit increase), lesion severity (HR 0.48 for shunt/valve vs severe), and older age (HR 0.95/month if < 1 year old and 0.94/year if > 1 year old; p < 0.05). Children with a care gap subsequently had more emergency department (ED) visits (Rate Ratio (RR) 1.59) and fewer inpatient encounters and procedures (RR 0.51, 0.35; p < 0.05). We found novel factors associated with gaps in care for cardiology follow-up in children with CHD and altered health care utilization with a gap. Our findings demonstrate a need to mitigate healthcare barriers and generate clear cardiology follow-up guidelines for children with CHD.

Metacognitive accuracy predicts self-reported quality of life following traumatic brain injury

OBJECTIVE

Metacognition and quality of life (QoL) are both adversely affected by traumatic brain injury (TBI), but the relation between them is not fully understood. As such, the purpose of this study was to determine the degree to which metacognitive accuracy predicts QoL in individuals with TBI.

METHODS

Eighteen participants with moderate-to-severe TBI completed a stimulus-response task requiring the discrimination of emotions depicted in pictures of faces and then provided a retrospective confidence judgment after each response. Metacognitive accuracy was calculated using participants' response accuracy and confidence judgment accuracy. Participants also completed the Quality of Life After Brain Injury (QOLIBRI) questionnaire to assess QoL in various areas of functioning.

RESULTS

Performance of a linear regression analysis revealed that higher metacognitive accuracy significantly predicted lower overall QoL. Additionally, higher metacognitive accuracy significantly predicted lower QoL related to cognition and physical limitations.

CONCLUSION

The study results provide evidence of an inverse relation between metacognitive performance and QoL following TBI. Metacognitive changes associated with TBI and their relation to QoL have several clinical implications for TBI rehabilitation.

DGKα/ζ inhibition lowers the TCR affinity threshold and potentiates antitumor immunity

Diacylglycerol kinases (DGKs) attenuate diacylglycerol (DAG) signaling by converting DAG to phosphatidic acid, thereby suppressing pathways downstream of T cell receptor signaling. Using a dual DGKα/ζ inhibitor (DGKi), tumor-specific CD8 T cells with different affinities (TRP1high and TRP1low), and altered peptide ligands, we demonstrate that inhibition of DGKα/ζ can lower the signaling threshold for T cell priming. TRP1high and TRP1low CD8 T cells produced more effector cytokines in the presence of cognate antigen and DGKi. Effector TRP1high- and TRP1low-mediated cytolysis of tumor cells with low antigen load required antigen recognition, was mediated by interferon-γ, and augmented by DGKi. Adoptive T cell transfer into mice bearing pancreatic or melanoma tumors synergized with single-agent DGKi or DGKi and antiprogrammed cell death protein 1 (PD-1), with increased expansion of low-affinity T cells and increased cytokine production observed in tumors of treated mice. Collectively, our findings highlight DGKα/ζ as therapeutic targets for augmenting tumor-specific CD8 T cell function.

Single-cell RNA sequencing of murine ankle joints over time reveals distinct transcriptional changes following Borrelia burgdorferi infection

Lyme disease is caused by the bacterial pathogen Borrelia burgdorferi, which can be readily modeled in laboratory mice. In order to understand the cellular and transcriptional changes that occur during B. burgdorferi infection, we conducted single-cell RNA sequencing (scRNA-seq) of ankle joints of infected C57BL/6 mice over time. We found that macrophages/monocytes, T cells, synoviocytes and fibroblasts all showed significant differences in gene expression of both inflammatory and non-inflammatory genes that peaked early and returned to baseline before the typical resolution of arthritis. Predictions of cellular interactions showed that macrophages appear to communicate extensively between different clusters of macrophages as well as with fibroblasts and synoviocytes. Our data give unique insights into the interactions between B. burgdorferi and the murine immune system over time and allow for a better understanding of mechanisms by which the dysregulation of the immune response may lead to prolonged symptoms in some patients.

Impact of Prenatal Diagnosis of Critical Congenital Heart Disease on Preoperative and Postoperative Outcomes

The objective of this study was to assess the relationship of prenatal diagnosis of critical congenital heart disease (CHD) to preoperative and postoperative patient findings. Retrospective analysis of neonates with critical CHD who underwent cardiothoracic surgery at one of four centers in North Carolina between 2008 and 2013. Surgical data collected by sites for submission to the Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHSD) and the North Carolina CHD Lifespan Database were queried. There were 715 patients with STS records; 558 linked to the NC-CHD database. Patients with prenatal diagnosis had a lower incidence of preoperative risk factors, including need for mechanical ventilation and presence of shock. However, prenatally diagnosed patients had worse short-term outcomes, including higher operative mortality, higher incidence of select postoperative complications, and longer LOS. There was no difference in one-year mortality. Our findings are consistent with current literature which suggests that prenatal diagnosis of critical CHD is associated with a more optimized preoperative clinical status. However, we found that patients with prenatal diagnoses had less favorable postoperative outcomes. This needs to be investigated further, but may be secondary to patient-specific factors, such as CHD disease severity.

Blockade of innate inflammatory cytokines TNF, IL-1, or IL-6 overcomes virotherapy-induced cancer equilibrium to promote tumor regression

Cancer therapeutics can lead to immune equilibrium in which the immune response controls tumor cell expansion without fully eliminating the cancer. The factors involved in this equilibrium remain incompletely understood, especially those that would antagonize the anti-tumor immune response and lead to tumor outgrowth. We previously demonstrated that continuous treatment with a non-replicating herpes simplex virus 1 expressing interleukin (IL)-12 induces a state of cancer immune equilibrium highly dependent on interferon-γ. We profiled the IL-12 virotherapy-induced immune equilibrium in murine melanoma, identifying blockade of innate inflammatory cytokines, tumor necrosis factor alpha (TNFα), IL-1β, or IL-6 as possible synergistic interventions. Antibody depletions of each of these cytokines enhanced survival in mice treated with IL-12 virotherapy and helped to overcome equilibrium in some tumors. Single-cell RNA-sequencing demonstrated that blockade of inflammatory cytokines resulted in downregulation of overlapping inflammatory pathways in macrophages, shifting immune equilibrium towards tumor clearance, and raising the possibility that TNFα blockade could synergize with existing cancer immunotherapies.

IFNγ is a central node of cancer immune equilibrium

Tumors in immune equilibrium are held in balance between outgrowth and destruction by the immune system. The equilibrium phase defines the duration of clinical remission and stable disease, and escape from equilibrium remains a major clinical problem. Using a non-replicating HSV-1 vector expressing interleukin-12 (d106S-IL12), we developed a mouse model of therapy-induced immune equilibrium, a phenomenon previously seen only in humans. This immune equilibrium was centrally reliant on interferon-γ (IFNγ). CD8+ T cell direct recognition of MHC class I, perforin/granzyme-mediated cytotoxicity, and extrinsic death receptor signaling such as Fas/FasL were all individually dispensable for equilibrium. IFNγ was critically important and played redundant roles in host and tumor cells such that IFNγ sensing in either compartment was sufficient for immune equilibrium. We propose that these redundant mechanisms of action are integrated by IFNγ to protect from oncogenic or chronic viral threats and establish IFNγ as a central node in therapy-induced immune equilibrium.

Third-Grade Academic Performance and Episodes of Cardiac Care Among Children with Congenital Heart Defects

Children with congenital heart defects (CHDs) are at risk for poor academic performance. The degree to which receipt of health care services is associated with adverse academic outcomes is not known. We examined the association between episodes of cardiac care and third-grade performance in children with CHD. We identified subjects between 1/1/2008 and 4/30/2012 among 5 centers in North Carolina. We classified children by CHD type and linked subjects to the state educational records. Any inpatient or outpatient cardiac encounter on a date of service was considered an encounter. We calculated the number of encounters by adding the number of inpatient or outpatient cardiac visits prior to the date of the end-of-grade (EOG) tests. We estimated the odds of failing third-grade reading or math EOG tests by episodes of care stratified at the 50th percentile, controlling for CHD type, maternal education, sex, race/ethnicity, birth weight, and gestational age. A total of 184 children had third-grade EOG scores linked to health care records. The median number of episodes of care was 4 (range: 1-60). Those with visits ˃ 50th percentile (> 4 encounters/year over the 4.3 year observation period) had 2.09 (95% CI 1.04, 4.21) greater odds of failing the math EOG compared to those ≤ 50th percentile (1-4 encounters). The third-grade math score declined by 1.5 points (P < 0.008) for every 10 episodes of care. There was no association of episodes of care on third-grade reading performance. Children with CHD with > 4 episodes of cardiac care/year may be at risk for delays in third-grade academic performance. Strategies to minimize school absenteeism may improve academic success in this population.

Disparities in Loss to Follow-Up Among Adults With Congenital Heart Disease in North Carolina

Background

The AHA/ACC Adult Congenital Heart Disease guidelines recommend that most adults with congenital heart disease (CHD) follow-up with CHD cardiologists every 1 to 2 years because longer gaps in care are associated with adverse outcomes. This study aimed to determine the proportion of patients in North Carolina who did not have recommended follow-up and to explore predictors of loss to follow-up.

Methods

Patients ages ≥18 years with a healthcare encounter from 2008 to 2013 in a statewide North Carolina database with an ICD-9 code for CHD were assessed. The proportion with cardiology follow-up within 24 months following index encounter was assessed with Kaplan-Meier estimates. Cox regression was utilized to identify demographic factors associated with differences in follow-up.

Results

2822 patients were identified. Median age was 35 years; 55% were female. 70% were white, 22% black, and 3% Hispanic; 36% had severe CHD. The proportion with 2-year cardiology follow-up was 61%. Those with severe CHD were more likely to have timely follow-up than those with less severe CHD (72% vs 55%, P < .01). Black patients had a lower likelihood of follow-up than white patients (56% vs 64%, P = .01). Multivariable Cox regression identified younger age, non-severe CHD, and non-white race as risk factors for a lower likelihood of follow-up by 2 years.

Conclusion

39% of adults with CHD in North Carolina are not meeting AHA/ACC recommendations for follow-up. Younger and minority patients and those with non-severe CHD were particularly vulnerable to inadequate follow-up; targeted efforts to retain these patients in care may be helpful.

Dose rate versus gantry speed performance evaluation for slow gantry speeds using DICOM RT plans

Purpose

Varian provides a DICOM RT Plan file that users can deliver to the electronic portal imaging device (EPID) panel to confirm the linear accelerator delivers consistent dose output across several regions of interest for varying dose rates and gantry speeds (DRGS). This work investigates if (a) the vendor‐provided DRGS DICOM RT Plan is valid within the gantry speed range of stereotactic body radiation therapy (SBRT) treatments, and (b) if output constancy is maintained at those gantry speeds on a TrueBeam.

Methods

Python code was written to iterate through all control points in the DICOM RT Plan files for 21 SBRT patients and the MU per degree values were calculated for each control point. A histogram was generated to illustrate how MU per degree was distributed among the control points from the patient plans. Then, the total number of MUs was increased in the vendor‐provided DRGS DICOM file to make a “modified DRGS DICOM RT Plan,” which surpasses the maximum MU per degree value found in the patient plans, forcing the gantry to travel at slow speeds and deliver more MU per degree over the same arc length (representative of those during SBRT treatment delivery). The modified DRGS DICOM RT Plan file was then delivered on a TrueBeam to acquire EPID images of the dose distribution. The EPID images were analyzed with Pylinac, a Python library that analyzes DICOM RT images acquired during routine linac QA.

Results

Over 83% of patient DICOM RT Plan control points had MU per degree values greater than the MU per degree values in the vendor‐provided DRGS DICOM file. The Pylinac analysis of the EPID‐acquired images found a maximum deviation of 0.4% from machine baselines.

Conclusions

The modified DRGS DICOM file can be used to determine if a TrueBeam linac is operating within specifications even when very low gantry speeds are reached.

The Role of Neuroinflammation in Neuropsychiatric Disorders Following Traumatic Brain Injury: A Systematic Review

BACKGROUND

Neuropsychiatric symptoms are common following traumatic brain injury (TBI), but their etiological onset remains unclear. Mental health research implicates neuroinflammation in the development of psychiatric disorders. The presence of neuroinflammatory responses after TBI thus prompts an investigation of their involvement in the emergence of neuropsychiatric disorders postinjury.

OBJECTIVE

Review the literature surrounding the role of neuroinflammation and immune response post-TBI in the development of neuropsychiatric disorders.

METHODS

A search of scientific databases was conducted for original, empirical studies in human subjects. Key words such as "neuroinflammation," "TBI," and "depression" were used to identify psychopathology as an outcome TBI and the relation to neuroinflammatory response.

RESULTS

Study results provide evidence of neuroinflammation mediated post-TBI neuropsychiatric disorders including anxiety, trauma/stress, and depression. Inflammatory processes and stress response dysregulation can lead to secondary cell damage, which promote the development and maintenance of neuropsychiatric disorders postinjury.

CONCLUSION

This review identifies both theoretical and empirical support for neuroinflammatory response as feasible mechanisms underlying neuropsychiatric disorders after TBI. Further understanding of these processes in this context has significant clinical implications for guiding the development of novel treatments to reduce psychiatric symptoms postinjury. Future directions to address current limitations in the literature are discussed.

Implementation and Evaluation of a TG-275 Key Recommendation: An Additional Early Physics Check: Early physics check implementation experience

PURPOSE

We report our experience of performing an extra, earlier physics plan check as recommended by the AAPM TG-100 and TG-275 reports. We assess utilization and timing of the extra check as well as time required in a medium-sized clinic.

METHODS

Timestamp data of quality checklist (QCL) items related to treatment planning and physics "pre-checks" for 3487 patients treated at our institution from February 2017 to February 2021 were retrospectively extracted and analyzed from the record and verify system. The dosimetry staff was interviewed for their perception of the value and efficacy of the practice.

RESULTS

Physics pre-checks were requested for 19.0% of plans. The number of requests declined from 43.9% of cases in 2017 to 18.4% in 2018. The introduction of automated plan check tools and a dosimetrist checklist further contributed to a drop in number of pre-check requests to 3.5% in 2019. For patients that received a physics pre-check, the treatment planning process was a median 3.6 hours longer compared to those without (p-value < 0.001). 12.9% of pre-check requests were cancelled by the dosimetrist after waiting a median time of 5.3 hours. There was a strong positive correlation (0.899) between a pre-check being requested and the time remaining until treatment start. Higher complexity plans and plans with a specific concern (e.g., possible collision) were more likely to have a pre-check requested.

CONCLUSIONS

Physics pre-checks have become standard practice for certain cases in our clinic. However, departmental perception was that, as a universal practice, waiting for a pre-check was not worth the time saved re-doing work on the few cases where an error was caught. Dosimetrist access to automated checking tools and checklists, which were motivated by the pre-check process, contributed to this perception.

Using Biomarkers to Predict Memantine Effects in Alzheimer's Disease: A Proposal and Proof-Of-Concept Demonstration

Memantine's benefits in Alzheimer's disease (AD) are modest and heterogeneous. We tested the feasibility of using sensitivity to acute memantine challenge to predict an individual's clinical response. Eight participants completed a double-blind challenge study of memantine (placebo versus 20 mg) effects on autonomic, subjective, cognitive, and neurophysiological measures, followed by a 24-week unblinded active-dose therapeutic trial (10 mg bid). Study participation was well tolerated. Subgroups based on memantine sensitivity on specific laboratory measures differed in their clinical response to memantine, some by large effect sizes. It appears feasible to use biomarkers to predict clinical sensitivity to memantine.

Increasing the value and efficiency of herbicide resistance surveys

The scale of herbicide resistance within a cropping region can be estimated and monitored using surveys of weed populations. The current approach to herbicide resistance surveys is time-consuming, logistically challenging and costly. Here we review past and current approaches used in herbicide resistance surveys with the aims of (i) defining effective survey methodologies, (ii) highlighting opportunities for improving efficiencies through the use of new technologies and (iii) identifying the value of repeated region-wide herbicide resistance surveys. One of the most extensively surveyed areas of the world's cropping regions is the Australian grain production region, with >2900 fields randomly surveyed in each of three surveys conducted over the past 15 years. Consequently, recommended methodologies are based on what has been learned from the Australian experience. Traditional seedling-based herbicide screening assays remain the most reliable and widely applicable method for characterizing resistance in weed populations. The use of satellite or aerial imagery to plan collections and image analysis to rapidly quantify screening results could complement traditional resistance assays by increasing survey efficiency and sampling accuracy. Global management of herbicide-resistant weeds would benefit from repeated and standardized surveys that track herbicide resistance evolution within and across cropping regions. © 2021 Society of Chemical Industry.

Causes of Death in Infants and Children with Congenital Heart Disease

With improved surgical outcomes, infants and children with congenital heart disease (CHD) may die from other causes of death (COD) other than CHD. We sought to describe the COD in youth with CHD in North Carolina (NC). Patients from birth to 20 years of age with a healthcare encounter between 2008 and 2013 in NC were identified by ICD-9 code. Patients who could be linked to a NC death certificate between 2008 and 2016 were included. Patients were divided by CHD subtypes (severe, shunt, valve, other). COD was compared between groups. Records of 35,542 patients < 20 years old were evaluated. There were 15,277 infants with an annual mortality rate of 3.5 deaths per 100 live births. The most frequent COD in infants (age < 1 year) were CHD (31.7%), lung disease (16.1%), and infection (11.4%). In 20,265 children (age 1 to < 20 years), there was annual mortality rate of 9.7 deaths per 1000 at risk. The most frequent COD in children were CHD (34.2%), neurologic disease (10.2%), and infection (9.5%). In the severe subtype, CHD was the most common COD. In infants with shunt-type CHD disease, lung disease (19.5%) was the most common COD. The mortality rate in infants was three times higher when compared to children. CHD is the most common underlying COD, but in those with shunt-type lesions, extra-cardiac COD is more common. A multidisciplinary approach in CHD patients, where development of best practice models regarding comorbid conditions such as lung disease and neurologic disease could improve outcomes in this patient population.

Evaluating emissions reductions from zero waste strategies under dynamic conditions: A case study from Boston

In 2018 and 2019 the City of Boston (Massachusetts, USA) conducted zero waste and carbon neutral planning efforts. Here we present the results of an accompanying analysis of the impacts of zero waste strategies on greenhouse gases (GHG) emissions associated with waste treatment. Emissions analysis in the waste sector is complicated by the contribution of significant indirect impacts that can exhibit temporal and spatial heterogeneity. For example, lifecycle GHG analysis of waste-to-energy combustion grants credits for the emissions avoided due to electricity generated from organic waste (biogenic carbon) that displaces electricity generation that could be carbon-emitting. As electricity grids decarbonize, this credit approaches zero. Long-term emissions planning needs to account for such dynamics to realistically assess the GHG mitigation potential associated with alternative waste management strategies. Here, we seek to capture these dynamics in a forward-looking analysis of waste sector emissions under a zero-waste strategy for the City of Boston. Using publicly available data sets such as EPA's Waste Reduction Model (WARM), we show that the implementation of zero waste strategies reduces the combustion of plastics and biomass in waste-to-energy (WtE) combustion facilities and associated GHG emissions. While WtE has been considered less-carbon intensive than other forms of waste treatment and fossil-based electricity generation, our analysis shows that more renewables will eventually eliminate the perceived GHG benefits associated with waste-to-energy combustion. While our approach provides policymakers with an understanding of the impacts of decisions in a dynamic context, we also identify common knowledge gaps in conducting forward-looking waste-GHG assessments.

Checkpoint blockade toxicities: Insights into autoimmunity and treatment

Checkpoint blockade has transformed not only the way cancers are treated, but also highlighted the importance of mounting a proper immune response against tumors. Despite advances in the field of immunotherapy, many patients develop a range of inflammatory toxicities that limit the efficacy of these therapies. These toxicities range from barrier site injury, such as colitis, to endocrine organ dysfunction, such as diabetes. In order to properly treat patients with cancer and avoid checkpoint blockade induced toxicities, we must gain a deeper understanding of the underlying mechanisms generating these adverse events. Cytotoxic and tissue-resident T cells likely play an important role in mediating some toxicities, though high levels of cytokines and the generation of auto-antibodies in other toxicities demonstrates these mechanisms are not all shared. Certain risk factors for specific toxicities may be able to predict who might benefit most from alternative therapies given the risk-benefit associated with checkpoint blockade. As the targets of checkpoint inhibitors have important functions in the prevention of autoimmunity, insights into risk factors and causes of toxicities will further our knowledge of fundamental immunology and enable the development of novel therapeutics.

Simultaneous Characterization of Implant Wear and Tribocorrosion Debris within Its Corresponding Tissue Response Using Infrared Chemical Imaging

Biotribology is one of the key branches in the field of artificial joint development. Wear and corrosion are among fundamental processes which cause material loss in a joint biotribological system; the characteristics of wear and corrosion debris are central to determining the in vivo bioreactivity. Much effort has been made elucidating the debris-induced tissue responses. However, due to the complexity of the biological environment of the artificial joint, as well as a lack of effective imaging tools, there is still very little understanding of the size, composition, and concentration of the particles needed to trigger adverse local tissue reactions, including periprosthetic osteolysis. Fourier transform infrared spectroscopic imaging (FTIR-I) provides fast biochemical composition analysis in the direct context of underlying physiological conditions with micron-level spatial resolution, and minimal additional sample preparation in conjunction with the standard histopathological analysis workflow. In this study, we have demonstrated that FTIR-I can be utilized to accurately identify fine polyethylene debris accumulation in macrophages that is not achievable using conventional or polarized light microscope with histological staining. Further, a major tribocorrosion product, chromium phosphate, can be characterized within its histological milieu, while simultaneously identifying the involved immune cell such as macrophages and lymphocytes. In addition, we have shown the different spectral features of particle-laden macrophages through image clustering analysis. The presence of particle composition variance inside macrophages could shed light on debris evolution after detachment from the implant surface. The success of applying FTIR-I in the characterization of prosthetic debris within their biological context may very well open a new avenue of research in the orthopedics community.

Causes of Death and Cardiovascular Comorbidities in Adults With Congenital Heart Disease

Background Little is known about the contemporary mortality experience among adults with congenital heart disease (CHD). The objectives of this study were to assess the age at death, presence of cardiovascular comorbidities, and most common causes of death among adults with CHD in a contemporary cohort within the United States. Methods and Results Patients with CHD who had a healthcare encounter between 2008 and 2013 at 1 of 5 comprehensive CHD centers in North Carolina were identified by International Classification of Diseases, Ninth Revision (ICD-9), code. Only patients who could be linked to a North Carolina death certificate between 2008 and 2016 and with age at death ≥20 years were included. Median age at death and underlying cause of death based on death certificate data were analyzed. The prevalence of acquired cardiovascular risk factors was determined from electronic medical record data. Among the 629 included patients, the median age at death was 64.2 years. Those with severe CHD (n=157, 25%), shunts (n=202, 32%), and valvular lesions (n=174, 28%) had a median age at death of 46.0, 65.0, and 73.3 years, respectively. Cardiovascular death was most common in adults with severe CHD (60%), with 40% of those deaths caused by CHD. Malignancy and ischemic heart disease were the most common causes of death in adults with nonsevere CHD. Hypertension and hyperlipidemia were common comorbidities among all CHD severity groups. Conclusions The most common underlying causes of death differed by lesion severity. Those with severe lesions most commonly died from underlying CHD, whereas those with nonsevere disease more commonly died from non-CHD causes.

Infrared spectral microscopy as a tool to monitor lung fibrosis development in a model system

Tissue fibrosis is a progressive and destructive disease process that can occur in many different organs including the liver, kidney, skin, and lungs. Fibrosis is typically initiated by inflammation as a result of chronic insults such as infection, chemicals and autoimmune diseases. Current approaches to examine organ fibrosis are limited to radiological and histological analyses. Infrared spectroscopic imaging offers a potential alternative approach to gain insight into biochemical changes associated with fibrosis progression. In this study, we demonstrate that IR imaging of a mouse model of pulmonary fibrosis can identify biochemical changes observed with fibrosis progression and the beginning of resolution using K-means analysis, spectral ratios and multivariate data analysis. This study demonstrates that IR imaging may be a useful approach to understand the biochemical events associated with fibrosis initiation, progression and resolution for both the clinical setting and for assessing novel anti-fibrotic drugs in a model system.

Primary Open Abductor Reconstruction: A 5 to 10-Year Study

BACKGROUND

Gluteal tears are recognized as the source of pain over the greater trochanter. We investigated the outcome of primary open abductor tendon reconstruction with a 5-10 year follow-up.

METHODS

One hundred sixty-five consecutive hips underwent an open abductor tendon reconstruction, with all tears confirmed preoperatively by magnetic resonance imaging. Oxford Hip Scores (OHS) were assessed at the initial visit, and at 5-10 years.

RESULTS

The average preoperative OHS was 22 (range 7-34) and average postoperative OHS was 40 a difference of 18 (P < .0001).

CONCLUSION

Surgical reconstruction of degenerate abductor tendons should be considered in the presence of a magnetic resonance imaging confirmed separation where clinical findings are consistent with the known tendon disruption. Open transosseous reconstruction reliably results in good pain relief at 5-10 years.

Neoleukin-2 enhances anti-tumour immunity downstream of peptide vaccination targeted by an anti-MHC class II VHH

Cancer-specific mutations can lead to peptides of unique sequence presented on MHC class I to CD8 T cells. These neoantigens can be potent tumour-rejection antigens, appear to be the driving force behind responsiveness to anti-CTLA-4 and anti-PD1/L1-based therapies and have been used to develop personalized vaccines. The platform for delivering neoantigen-based vaccines has varied, and further optimization of both platform and adjuvant will be necessary to achieve scalable vaccine products that are therapeutically effective at a reasonable cost. Here, we developed a platform for testing potential CD8 T cell tumour vaccine candidates. We used a high-affinity alpaca-derived VHH against MHC class II to deliver peptides to professional antigen-presenting cells. We show in vitro and in vivo that peptides derived from the model antigen ovalbumin are better able to activate naive ovalbumin-specific CD8 T cells when conjugated to an MHC class II-specific VHH when compared with an irrelevant control VHH. We then used the VHH-peptide platform to evaluate a panel of candidate neoantigens in vivo in a mouse model of pancreatic cancer. None of the candidate neoantigens tested led to protection from tumour challenge; however, we were able to show vaccine-induced CD8 T cell responses to a melanoma self-antigen that was augmented by combination therapy with the synthetic cytokine mimetic Neo2/15.

Standardization of complex biologically derived spectrochemical datasets

Spectroscopic techniques such as Fourier-transform infrared (FTIR) spectroscopy are used to study interactions of light with biological materials. This interaction forms the basis of many analytical assays used in disease screening/diagnosis, microbiological studies, and forensic/environmental investigations. Advantages of spectrochemical analysis are its low cost, minimal sample preparation, non-destructive nature and substantially accurate results. However, an urgent need exists for repetition and validation of these methods in large-scale studies and across different research groups, which would bring the method closer to clinical and/or industrial implementation. For this to succeed, it is important to understand and reduce the effect of random spectral alterations caused by inter-individual, inter-instrument and/or inter-laboratory variations, such as variations in air humidity and CO₂ levels, and aging of instrument parts. Thus, it is evident that spectral standardization is critical to the widespread adoption of these spectrochemical technologies. By using calibration transfer procedures, in which the spectral response of a secondary instrument is standardized to resemble the spectral response of a primary instrument, different sources of variation can be normalized into a single model using computational-based methods, such as direct standardization (DS) and piecewise direct standardization (PDS); therefore, measurements performed under different conditions can generate the same result, eliminating the need for a full recalibration. Here, we have constructed a protocol for model standardization using different transfer technologies described for FTIR spectrochemical applications. This is a critical step toward the construction of a practical spectrochemical analysis model for daily routine analysis, where uncertain and random variations are present.

The challenge of herbicide resistance around the world: a current summary

Herbicide-resistant weeds have been observed since the early years of synthetic herbicide development in the 1950s and 1960s. Since that time there has been a consistent increase in the number of cases of herbicide resistance and the impact of herbicide-resistant weeds. Although the nature of crop production varies widely around the world, herbicides have become a primary tool for weed control in most areas. Dependence on herbicides continues to increase as global populations migrate away from rural areas to cities and the agricultural labor force declines. This increased use of herbicides and the concurrent selection pressure have resulted in a rise in cases of multiple resistance, leaving some farmers with few or no herbicide options for certain weed infestations. Global population and economic forces drive many farmer choices regarding crop production and weed control. The challenge is how to insert best management practices into the decision-making process while addressing various economic and regulatory needs. This review endeavors to provide a current overview of herbicide resistance challenges in the major crop production areas of the world and discusses some research initiatives designed to address portions of the problem. © 2017 Society of Chemical Industry.

Opportunities and challenges for harvest weed seed control in global cropping systems

The opportunity to target weed seeds during grain harvest was established many decades ago following the introduction of mechanical harvesting and the recognition of high weed-seed retention levels at crop maturity; however, this opportunity remained largely neglected until more recently. The introduction and adoption of harvest weed seed control (HWSC) systems in Australia has been in response to widespread occurrence of herbicide-resistant weed populations. With diminishing herbicide resources and the need to maintain highly productive reduced tillage and stubble-retention practices, growers began to develop systems that targeted weed seeds during crop harvest. Research and development efforts over the past two decades have established the efficacy of HWSC systems in Australian cropping systems, where widespread adoption is now occurring. With similarly dramatic herbicide resistance issues now present across many of the world's cropping regions, it is timely for HWSC systems to be considered for inclusion in weed-management programs in these areas. This review describes HWSC systems and establishing the potential for this approach to weed control in several cropping regions. As observed in Australia, the inclusion of HWSC systems can reduce weed populations substantially reducing the potential for weed adaptation and resistance evolution. © 2017 Society of Chemical Industry.

The evolution of size, shape, and surface morphology of gold nanorods

We investigate the transformation of single crystal gold nanorod surface morphology over extended growth times. After initial rapid anisotropic growth and disappearance of {111} bridging facets, the aspect ratios converge across AgNO₃ concentrations. The surface morphology transitions from faceted to curved. These observations imply the final aspect ratio has little dependence on the AgNO₃ concentration, consistent with primary control of the AgNO₃ over aspect ratio occurring at the symmetry breaking point.

Selecting optimal features from Fourier transform infrared spectroscopy for discrete-frequency imaging

Tissue histology utilizing chemical and immunohistochemical labels plays an important role in biomedicine and disease diagnosis. Recent research suggests that mid-infrared (IR) spectroscopic imaging may augment histology by providing quantitative molecular information. One of the major barriers to this approach is long acquisition time using Fourier-transform infrared (FTIR) spectroscopy. Recent advances in discrete frequency sources, particularly quantum cascade lasers (QCLs), may mitigate this problem by allowing selective sampling of the absorption spectrum. However, DFIR imaging only provides a significant advantage when the number of spectral samples is minimized, requiring a priori knowledge of important spectral features. In this paper, we demonstrate the use of a GPU-based genetic algorithm (GA) using linear discriminant analysis (LDA) for DFIR feature selection. Our proposed method relies on pre-acquired broadband FTIR images for feature selection. Based on user-selected criteria for classification accuracy, our algorithm provides a minimal set of features that can be used with DFIR in a time-frame more practical for clinical diagnosis.

CRISPR/Cas9-Mediated Genome Editing in Epstein-Barr Virus-Transformed Lymphoblastoid B-Cell Lines

Epstein-Barr virus (EBV) efficiently transforms primary human B cells into immortalized lymphoblastoid cell lines (LCLs), which are extensively used in human genetic, immunological and virological studies. LCLs provide unlimited sources of DNA for genetic investigation, but can be difficult to manipulate, for instance because low retroviral or lentiviral transduction frequencies hinder experiments that require co-expression of multiple components. This unit details Clustered Regularly Interspaced Short Palindromic Repeats (CRISPR)/Cas9 engineering for robust LCL genome editing. We describe the generation and delivery of single-guide RNAs (sgRNAs), or dual-targeting sgRNAs, via lentiviral transduction of LCLs that stably express Cas9 protein. CRISPR/Cas9 editing allows LCL loss-of-function studies, including knock-out of protein-coding genes or deletion of DNA regulatory elements, and can be adapted for large-scale screening approaches. Low transfection efficiencies are a second barrier to performing CRISPR editing in LCLs, which are not typically lipid-transfectable. To circumvent this barrier, we provide an optimized protocol for LCL nucleofection of Cas9/sgRNA ribonucleoprotein complexes (RNPs) as an alternative route to achieve genome editing in LCLs. These editing approaches can also be employed in other B-cell lines, including Burkitt lymphoma and diffuse large B-cell lymphoma cells, and are highly reproducible. © 2018 by John Wiley & Sons, Inc.

A Mechanism for Symmetry Breaking and Shape Control in Single-Crystal Gold Nanorods

The phenomenon of symmetry breaking-in which the order of symmetry of a system is reduced despite manifest higher-order symmetry in the underlying fundamental laws-is pervasive throughout science and nature, playing a critical role in fields ranging from particle physics and quantum theory to cosmology and general relativity. For the growth of crystals, symmetry breaking is the crucial step required to generate a macroscopic shape that has fewer symmetry elements than the unit cell and/or seed crystal from which it grew. Advances in colloid synthesis have enabled a wide variety of nanocrystal morphologies to be achieved, albeit empirically. Of the various nanoparticle morphologies synthesized, gold nanorods have perhaps been the most intensely studied, thanks largely to their unique morphology-dependent optical properties and exciting application potential. However, despite intense research efforts, an understanding of the mechanism by which a single crystal breaks symmetry and grows anisotropically has remained elusive, with many reports presenting seemingly conflicting data and theories. A fundamental understanding of the symmetry breaking process is needed to provide a rational framework upon which future synthetic approaches can be built. Inspired by recent experimental results and drawing upon the wider literature, we present a mechanism for gold nanorod growth from the moments prior to symmetry breaking to the final product. In particular, we describe the steps by which a cuboctahedral seed particle breaks symmetry and undergoes anisotropic growth to form a nanorod. With an emphasis on the evolving crystal structure, we highlight the key geometrical and chemical drivers behind the symmetry breaking process and factors that govern the formation and growth of nanorods, including control over the crystal width, length, and surface faceting. We propose that symmetry breaking is induced by an initial formation of a new surface structure that is stabilized by the deposition of silver, thus preserving this facet in the embryonic nanorod. These new surfaces initially form stochastically as truncations that remove high-energy edge atoms at the intersection of existing {111} facets and represent the beginnings of a {011}-type surface. Crucially, the finely tuned [HAuCl₄]:[AgNO₃] ratio and reduction potential of the system mean that silver deposition can occur on the more atomically open surface but not on the pre-existing lower-index facets. The stabilized surfaces develop into side facets of the nascent nanorod, while the largely unpassivated {111} facets are the predominant site of Au atom deposition. Growth in the width direction is tightly controlled by a self-sustaining cycle of galvanic replacement and silver deposition. It is the [HAuCl₄]:[AgNO₃] ratio that directly determines the particle size at which the more open atomic surfaces can be stabilized by silver and the rate of growth in the width direction following symmetry breaking, thus explaining the known aspect ratio control with Ag ion concentration. We describe the evolving surface faceting of the nanorod and the emergence of higher-index facets. Collectively, these observations allow us to identify facet-size and edge-atom effects as a simple fundamental driver of symmetry breaking and the subsequent development of new surfaces in the presence of adsorbates.

Infrared spectroscopic imaging: Label-free biochemical analysis of stroma and tissue fibrosis

Infrared spectroscopic tissue imaging is a potentially powerful adjunct tool to current histopathology techniques. By coupling the biochemical signature obtained through infrared spectroscopy to the spatial information offered by microscopy, this technique can selectively analyze the chemical composition of different features of unlabeled, unstained tissue sections. In the past, the tissue features that have received the most interest were parenchymal and epithelial cells, chiefly due to their involvement in dysplasia and progression to carcinoma; however, the field has recently turned its focus toward stroma and areas of fibrotic change. These components of tissue present an untapped source of biochemical information that can shed light on many diverse disease processes, and potentially hold useful predictive markers for these same pathologies. Here we review the recent applications of infrared spectroscopic imaging to stromal and fibrotic regions of diseased tissue, and explore the potential of this technique to advance current capabilities for tissue analysis.

Accounting for tissue heterogeneity in infrared spectroscopic imaging for accurate diagnosis of thyroid carcinoma subtypes

Fourier transform infrared (FT-IR) microscopy was used to image tissue samples from twenty patients diagnosed with thyroid carcinoma. The spectral data were then used to differentiate between follicular thyroid carcinoma and follicular variant of papillary thyroid carcinoma using principle component analysis coupled with linear discriminant analysis and a Naïve Bayesian classifier operating on a set of computed spectral metrics. Classification of patients' disease type was accomplished by using average spectra from a wide region containing follicular cells, colloid, and fibrosis; however, classification of disease state at the pixel level was only possible when the extracted spectra were limited to follicular epithelial cells in the samples, excluding the relatively uninformative areas of fibrosis. The results demonstrate the potential of FT-IR microscopy as a tool to assist in the difficult diagnosis of these subtypes of thyroid cancer, and also highlights the importance of selectively and separately analyzing spectral information from different features of a tissue of interest.

Landscape of Innovation for Cardiovascular Pharmaceuticals: From Basic Science to New Molecular Entities

PURPOSE

This study examines the complete timelines of translational science for new cardiovascular therapeutics from the initiation of basic research leading to identification of new drug targets through clinical development and US Food and Drug Administration (FDA) approval of new molecular entities (NMEs) based on this research.

METHODS

This work extends previous studies by examining the association between the growth of research on drug targets and approval of NMEs associated with these targets. Drawing on research on innovation in other technology sectors, where technological maturity is an important determinant in the success or failure of new product development, an analytical model was used to characterize the growth of research related to the known targets for all 168 approved cardiovascular therapeutics.

FINDINGS

Categorizing and mapping the technological maturity of cardiovascular therapeutics reveal that (1) there has been a distinct transition from phenotypic to targeted methods for drug discovery, (2) the durations of clinical and regulatory processes were significantly influenced by changes in FDA practice, and (3) the longest phase of the translational process was the time required for technology to advance from initiation of research to a statistically defined established point of technology maturation (mean, 30.8 years).

IMPLICATIONS

This work reveals a normative association between metrics of research maturation and approval of new cardiovascular therapeutics and suggests strategies for advancing translational science by accelerating basic and applied research and improving the synchrony between the maturation of this research and drug development initiatives.

CRISPR/Cas9 Screens Reveal Epstein-Barr Virus-Transformed B Cell Host Dependency Factors

Epstein-Barr virus (EBV) causes endemic Burkitt lymphoma (BL) and immunosuppression-related lymphomas. These B cell malignancies arise by distinct transformation pathways and have divergent viral and host expression programs. To identify host dependency factors resulting from these EBV+, B cell-transformed cell states, we performed parallel genome-wide CRISPR/Cas9 loss-of-function screens in BL and lymphoblastoid cell lines (LCLs). These highlighted 57 BL and 87 LCL genes uniquely important for their growth and survival. LCL hits were enriched for EBV-induced genes, including viral super-enhancer targets. Our systematic approach uncovered key mechanisms by which EBV oncoproteins activate the PI3K/AKT pathway and evade tumor suppressor responses. LMP1-induced cFLIP was found to be critical for LCL defense against TNFα-mediated programmed cell death, whereas EBV-induced BATF/IRF4 were critical for BIM suppression and MYC induction in LCLs. Finally, EBV super-enhancer-targeted IRF2 protected LCLs against Blimp1-mediated tumor suppression. Our results identify viral transformation-driven synthetic lethal targets for therapeutic intervention.

Why was resistance to shorter-acting pre-emergence herbicides slower to evolve?

BACKGROUND

Across several agricultural systems the evolution of herbicide resistance has occurred more rapidly to post-emergence than pre-emergence herbicides; however, the reasons for this are not clear. We used a new simulation model to investigate whether interactions between differences in order of application and weed cohorts affected could explain this historically observed difference between the herbicide groups.

RESULTS

A 10 year delay in resistance evolution was predicted for a shorter-acting residual pre-emergence (cf. post-emergence), when all other parameters were identical. Differences in order of application between pre- and post-emergence herbicides had minimal effect on rates of resistance evolution when similar weed cohorts were affected.

CONCLUSION

This modelling suggested that the historically observed lower levels of resistance to pre-emergence herbicides are most likely to be due to the smaller number of weed cohorts affected by many pre-emergence herbicides. The lower number of weed cohorts affected by pre-emergence herbicides necessitated the use of additional, effective control measures, thereby reducing resistance evolution. This study highlights the advantages of applying multiple control measures to each weed cohort. © 2016 Society of Chemical Industry.

Recurrent selection with reduced 2,4-D amine doses results in the rapid evolution of 2,4-D herbicide resistance in wild radish (Raphanus raphanistrum L.)

BACKGROUND

When used at effective doses, weed resistance to auxinic herbicides has been slow to evolve when compared with other modes of action. Here we report the evolutionary response of a herbicide-susceptible population of wild radish (Raphanus raphanistrum L.) and confirm that sublethal doses of 2,4-dichlorophenoxyacetic acid (2,4-D) amine can lead to the rapid evolution of 2,4-D resistance and cross-resistance to acetolactate synthase (ALS)-inhibiting herbicides.

RESULTS

Following four generations of 2,4-D selection, the progeny of a herbicide-susceptible wild radish population evolved 2,4-D resistance, increasing the LD₅₀ from 16 to 138 g ha^-1 . Along with 2,4-D resistance, cross-resistance to the ALS-inhibiting herbicides metosulam (4.0-fold) and chlorsulfuron (4.5-fold) was evident. Pretreatment of the 2,4-D-selected population with the cytochrome P450 inhibitor malathion restored chlorsulfuron to full efficacy, indicating that cross-resistance to chlorsulfuron was likely due to P450-catalysed enhanced rates of herbicide metabolism.

CONCLUSION

This study is the first to confirm the rapid evolution of auxinic herbicide resistance through the use of low doses of 2,4-D and serves as a reminder that 2,4-D must always be used at highly effective doses. With the introduction of transgenic auxinic-herbicide-resistant crops in the Americas, there will be a marked increase in auxinic herbicide use and therefore the risk of resistance evolution. Auxinic herbicides should be used only at effective doses and with diversity if resistance is to remain a minimal issue. © 2016 Society of Chemical Industry.

CRISPR/Cas9 Screens Reveal Requirements for Host Cell Sulfation and Fucosylation in Bacterial Type III Secretion System-Mediated Cytotoxicity

Type III secretion systems (T3SSs) inject bacterial effector proteins into host cells and underlie the virulence of many gram-negative pathogens. Studies have illuminated bacterial factors required for T3SS function, but the required host processes remain largely undefined. We coupled CRISPR/Cas9 genome editing technology with the cytotoxicity of two Vibrio parahaemolyticus T3SSs (T3SS1 and T3SS2) to identify human genome disruptions conferring resistance to T3SS-dependent cytotoxicity. We identity non-overlapping genes required for T3SS1- and T3SS2-mediated cytotoxicity. Genetic ablation of cell surface sulfation reduces bacterial adhesion and thereby alters the kinetics of T3SS1-mediated cytotoxicity. Cell surface fucosylation is required for T3SS2-dependent killing, and genetic inhibition of fucosylation prevents membrane insertion of the T3SS2 translocon complex. These findings reveal the importance of ubiquitous surface modifications for T3SS function, potentially explaining the broad tropism of V. parahaemolyticus, and highlight the utility of genome-wide CRISPR/Cas9 screens to discover processes underlying host-pathogen interactions.

Surface Electromyographic Activity in Total Laryngectomy Patients following Laryngeal Nerve Transfer to Neck Strap Muscles

Hands-free triggering and pitch control would improve electrolarynx devices, which are inconvenient to use and sound unnatural. The present study tested the strategy of salvaging voice-related neural signals for hands-free electrolarynx control either by transferring cut recurrent laryngeal nerves (RLNs) to denervated neck strap muscles or by preserving strap muscles with their normal innervation. An RLN nerve transfer was performed at the time of total laryngectomy in 8 individuals, and in 5 of these subjects, strap muscles with intact ansa cervicalis innervation were also preserved for comparison. Neck surface electromyography performed over the strap muscles was used periodically for more than 1 year on phonatory and nonphonatory tasks. Signals were eventually obtained in all subjects from both RLN-innervated and ansa-innervated strap muscles that correlated with speech production. After 1 year, RLN-driven signals were larger than ansa-driven signals in magnitude, and their timing appeared better correlated with intended phonation. The results show that neck surface electromyography is an effective control source for hands-free electrolarynx activation, and that RLN transfer may provide the best approach for obtaining phonation-related activity.

Infrared spectroscopic imaging detects chemical modifications in liver fibrosis due to diabetes and disease

The importance of stroma as a rich diagnostic region in tissue biopsies is growing as there is an increasing understanding that disease processes in multiple organs can affect the composition of adjacent connective tissue regions. This may be especially true in the liver, since this organ's central metabolic role exposes it to multiple disease processes. We use quantum cascade laser infrared spectroscopic imaging to study changes in the chemical status of hepatocytes and fibrotic regions of liver tissue that result from the progression of liver cirrhosis to hepatocellular carcinoma and the potentially confounding effects of diabetes mellitus.

Using Raman spectroscopy to characterize biological materials

Raman spectroscopy can be used to measure the chemical composition of a sample, which can in turn be used to extract biological information. Many materials have characteristic Raman spectra, which means that Raman spectroscopy has proven to be an effective analytical approach in geology, semiconductor, materials and polymer science fields. The application of Raman spectroscopy and microscopy within biology is rapidly increasing because it can provide chemical and compositional information, but it does not typically suffer from interference from water molecules. Analysis does not conventionally require extensive sample preparation; biochemical and structural information can usually be obtained without labeling. In this protocol, we aim to standardize and bring together multiple experimental approaches from key leaders in the field for obtaining Raman spectra using a microspectrometer. As examples of the range of biological samples that can be analyzed, we provide instructions for acquiring Raman spectra, maps and images for fresh plant tissue, formalin-fixed and fresh frozen mammalian tissue, fixed cells and biofluids. We explore a robust approach for sample preparation, instrumentation, acquisition parameters and data processing. By using this approach, we expect that a typical Raman experiment can be performed by a nonspecialist user to generate high-quality data for biological materials analysis.

Directional selection for flowering time leads to adaptive evolution in Raphanus raphanistrum (Wild radish)

Herbicides have been the primary tool for controlling large populations of yield depleting weeds from agro‐ecosystems, resulting in the evolution of widespread herbicide resistance. In response, nonherbicidal techniques have been developed which intercept weed seeds at harvest before they enter the soil seed bank. However, the efficiency of these techniques allows an intense selection for any trait that enables weeds to evade collection, with early‐flowering ecotypes considered likely to result in early seed shedding. Using a field‐collected wild radish population, five recurrent generations were selected for early maturity and three generations for late maturity. Phenology associated with flowering time and growth traits were measured. Our results demonstrate the adaptive capacity of wild radish to halve its time to flowering following five generations of early‐flowering selection. Early‐maturing phenotypes had reduced height and biomass at maturity, leading to less competitive, more prostrate growth forms. Following three generations of late‐flowering selection, wild radish doubled its time to flowering time leading to increased biomass and flowering height at maturity. This study demonstrates the potential for the rapid evolution in growth traits in response to highly effective seed collection techniques that imposed a selection on weed populations within agro‐ecosystems at harvest.

A label-free approach by infrared spectroscopic imaging for interrogating the biochemistry of diabetic nephropathy progression

Routine histology, the current gold standard, involves staining for specific biomolecules. However, untapped biochemical information in tissue can be gathered using biochemical imaging. Infrared spectroscopy is an emerging modality that allows label-free chemical imaging to derive biochemical information (such as protein, lipids, DNA, collagen) from tissues. Here we employed this technology in order to better predict the development of diabetic nephropathy. Using human primary kidney biopsies or nephrectomies, we obtained tissue from 4 histologically normal kidneys, 4 histologically normal kidneys from diabetic subjects, and 5 kidneys with evidence of diabetic nephropathy. A biochemical signature of diabetic nephropathy was derived that enabled prediction of nephropathy based on the ratio of only 2 spectral frequencies. Nonetheless, using the entire spectrum of biochemical information, we were able to detect renal disease with near-perfect accuracy. Additionally, study of sequential protocol biopsies from 3 transplanted kidneys showed biochemical changes even prior to clinical manifestation of diabetic nephropathy. Thus, infrared imaging can identify critical biochemical alterations that precede morphologic changes, potentially allowing for earlier intervention.