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Significance of Radiomics in Predicting Local Control for Patients with Malignant Liver Tumors Treated Using Stereotactic Body Radiotherapy. Int J Radiat Oncol Biol Phys 2023; 117:e465. [PMID: 37785484 DOI: 10.1016/j.ijrobp.2023.06.1666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) We routinely deliver Stereotactic Body Radiotherapy (SBRT) in malignant liver tumors using planning computed tomography (CT) and Magnetic Resonance Images (MRI) to aid target definition. In this study, we extracted radiomic features from the MR images to predict local control (LC) post-SBRT. MATERIALS/METHODS We retrospectively analyzed patients with either hepatocellular cancers (HCCs) or liver metastases (Mets) treated with SBRT between Aug 2014 and Aug 2020. All patients had CT simulation followed by 1.5 Tesla planning MRI in treatment position. Contrast enhanced T1 VIBE and T2 Haste MR sequences were registered with planning CT for target definition. Radiomic features were extracted from Gross Tumor Volumes (GTV) masked out of 60 seconds post contrast T1 VIBE MR images using the Radiomics calculator tool RaCaT. The output included 480 (408 textural, 50 intensity and 22 morphological) features for each target. Principal Component Analysis of the outputs obtained from all the targets yielded 20 radiomic feature clusters after computational prioritization. These clusters were correlated to LC outcomes at various time points post-SBRT. LC was defined as non-progressive disease. Accuracy of predictions was measured by area under (AUC) receiver operating characteristic curve. Cox regression analysis was done to find univariate and multivariate clinical [HCCs vs. Mets, single vs. multiple lesions, previous local therapy (yes vs. no), GTV volume (≤40 vs. >40 cc)], radiomic and dosimetric predictors (continuous) of LC. RESULTS In total, 97 patients received SBRT to 122 lesions. The median dose prescribed was 45 Gy (range, 30-50 Gy). Median age was 69 years (interquartile range, IQR 61-73 yrs.). 59 patients had HCCs and 38 had Mets. 24 lesions had prior ablative therapy. 75 patients had one target, and 22 had multiple targets. Median GTV was 43.5 cc (IQR 23.4-78.6 cc). Median follow up was 16.6 months (IQR 9.7-27.2 mths). Median LC was 13.6 months (IQR 8.0-23.5 mths). On univariate analysis, histology (HCCs vs. Mets; Hazard ratio (HR) 2.9, 95% CI 1.4-6.4; p < 0.006), radiomic clusters (p < 0.006) and the max., mean, and min. doses to GTV and Planning Target Volumes correlated with improved LC (all p-values < 0.05). On multivariate analysis, histology (HCCs vs. Mets; HR 4.4, 95% CI 1.6-12.3; p = 0.004), radiomic clusters (p = 0.034) and prescription dose (p = 0.048) were significant covariates. Specifically, the 20 radiomic clusters were predictive of LC, and the accuracy of predictions showed promise with AUC values of 0.74, 0.80, and 0.81 at 12, 24, and 36 months post-SBRT, respectively. AUC values for LC in HCCs vs. Mets at 12, 24, and 36 months were 0.83, 0.77, and 0.70, and 0.66, 0.77, and 0.88, respectively. CONCLUSION MR-based radiomics predict LC post-SBRT in patients with malignant liver tumors. Further research focused on independent validation of the model is required to explore its clinical use.
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Clinical efficacy of the virtual fracture clinic: analysis of 17,269 referrals by type of injury. Ann R Coll Surg Engl 2023; 105:441-445. [PMID: 36374286 PMCID: PMC10149252 DOI: 10.1308/rcsann.2022.0118] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2022] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Numerous studies have deemed the virtual fracture clinic (VFC) model to be both cost and clinically effective. However, very few of these studies have analysed the type of injuries seen in the VFC. The objectives of this study were to assess the clinical effectiveness of the VFC and analyse the types of injuries that lead to patients re-presenting in the face-to-face fracture clinic after being discharged virtually. METHODS This is a retrospective study analysing 17,269 patients referred to the VFC between September 2017 and February 2020. Data regarding the type of presenting injury were collected to understand which injuries required further management after being discharged virtually. Patient clinic letters provided data regarding the purpose and outcomes of VFC referrals as well as face-to-face appointments. Theatre lists were cross-referenced to extract data regarding surgical management. RESULTS In total, 57.37% (9,908) patients were discharged virtually. Of these patients, 92.52% were discharged successfully and 7.48% re-presented to the fracture clinic: 98.11% were managed conservatively and 1.88% required surgery. The highest number of failed discharges were for distal radius fractures (109, 14.69%). Face-to-face follow-up in fracture clinic was requested for 37.06% (6,400) of patients; 4.98% of them required surgical intervention. Some 5.56% (961) of referrals were removed from our analysis: 807 were inappropriate referrals and 154 were deemed suitable for multidisciplinary team discussion. The trust has saved an average of £702,205 annually since introduction of the VFC. CONCLUSIONS The VFC model delivers as promised in terms of clinical efficacy and cost management. Injury types showing higher numbers of unsuccessful discharges could benefit from having modified management pathways.
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Factors Associated With Strong Opioid Use For Non-Cancer Pain In Patients With Chronic Intestinal Failure. Clin Nutr ESPEN 2023. [DOI: 10.1016/j.clnesp.2022.09.289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2023]
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WCN23-0234 A PROSPECTIVE STUDY ON SPECTRUM OF RENAL DISEASE IN MALIGNANCY. Kidney Int Rep 2023. [DOI: 10.1016/j.ekir.2023.02.222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2023] Open
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Ranking mAb-excipient interactions in biologics formulations by NMR spectroscopy and computational approaches. MAbs 2023; 15:2212416. [PMID: 37218059 DOI: 10.1080/19420862.2023.2212416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2023] Open
Abstract
Excipients are added to biopharmaceutical formulations to enhance protein stability and enable the development of robust formulations with acceptable physicochemical properties, but the mechanism by which they confer stability is not fully understood. Here, we aimed to elucidate the mechanism through direct experimental evidence of the binding affinity of an excipient to a monoclonal antibody (mAb), using saturation transfer difference (STD) nuclear magnetic resonance (NMR) spectroscopic method. We ranked a series of excipients with respect to their dissociation constant (KD) and nonspecific binding constants (Ns). In parallel, molecular dynamic and site identification by ligand competitive saturation (SILCS)-Monte Carlo simulations were done to rank the excipient proximity to the proteins, thereby corroborating the ranking by STD NMR. Finally, the excipient ranking by NMR was correlated with mAb conformational and colloidal stability. Our approach can aid excipient selection in biologic formulations by providing insights into mAb-excipient affinities before conventional and time-consuming excipient screening studies are conducted.
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Pseudogout Causing Thoracic Outlet Syndrome. Am J Clin Pathol 2022. [DOI: 10.1093/ajcp/aqac126.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Abstract
Introduction/Objective
Calcium pyrophosphate dihydrate (CPPD) crystal deposition or pseudogout is a common entity encountered in routine practice. However, when a common entity presents in uncommon locations with unusual clinical manifestations, it creates a diagnostic conundrum. Pseudogout commonly occurs in the joint extremities including knee, wrist, shoulder, hip, and ankle joints. The sternoclavicular joint is a rare site for pseudogout with very low incidence. To the best of our knowledge, there are only two other cases of pseudogout mimicking a tumor causing vascular obstruction in the literature.
Methods/Case Report
A 63 year old male presented with an enlarging supraclavicular mass. A computed tomography angiography scan of the chest revealed an irregular soft tissue mass located behind the medial clavicle measuring up to 4 cm and was noted to compress and partially occlude the right subclavian vein. Partial occlusion of right axillary vein, right internal jugular vein, and right brachiocephalic vein were also noted on imaging. The venous compression led to outflow obstruction and resultant recurrent deep vein thrombosis of the right upper extremity. Due to compression by the mass, he required stenting of the right subclavian vein which unfortunately reoccluded. Subsequently, the patient underwent excision of the mass and partial resection of the first rib with decompression of the thoracic outlet. The excisional biopsy revealed dense rhomboid-shaped CPPD crystal depositions in irregular nodules within a background of fibrinoid material and fragments of unremarkable cartilaginous tissue. The patients compressive symptoms were relieved following the excision. While clinically and radiologically the mass was concerning for a malignant tumor, histological examination provided a definitive diagnosis of a benign process.
Results (if a Case Study enter NA)
NA.
Conclusion
Pseudogout is a rare mimicker of bone and soft tissue tumors and differentiation from an enchondroma, or grade 1 chondrosarcoma becomes a challenge especially on small tissue biopsies and is a possible diagnostic pitfall.
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New Development in Understanding Drug-Polymer Interactions in Pharmaceutical Amorphous Solid Dispersions from Solid-State Nuclear Magnetic Resonance. Mol Pharm 2022; 19:3685-3699. [PMID: 36037249 DOI: 10.1021/acs.molpharmaceut.2c00479] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Pharmaceutical amorphous solid dispersions (ASDs) represent a widely used technology to increase the bioavailability of active pharmaceutical ingredients (APIs). ASDs are based on an amorphous API dispersed in a polymer, and their stability is driven by the presence of strong intermolecular interactions between these two species (e.g., hydrogen bond, electrostatic interactions, etc.). The understanding of these interactions at the atomic level is therefore crucial, and solid-state nuclear magnetic resonance (NMR) has demonstrated itself as a very powerful technique for probing API-polymer interactions. Other reviews have also reported exciting approaches to study the structures and dynamic properties of ASDs and largely focused on the study of API-polymer miscibility and on the identification of API-polymer interactions. Considering the increased use of NMR in the field, the aim of this Review is to specifically highlight recent experimental strategies used to identify API-polymer interactions and report promising recent examples using one-dimensional (1D) and two-dimensional (2D) experiments by exploiting the following emerging approaches of very-high magnetic field and ultrafast magic angle spinning (MAS). A range of different ASDs spanning APIs and polymers with varied structural motifs is targeted to illustrate new ways to understand the mechanism of stability of ASDs to enable the design of new dispersions.
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PHYSICOCHEMICAL AND FUNCTIONAL CHARACTERISATION OF A FOOD INGREDIENT BASED ON OKARA CONTAINING PROBIOTICS. FOOD AND BIOPRODUCTS PROCESSING 2022. [DOI: 10.1016/j.fbp.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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43P Malignant bowel obstruction in advanced ovarian cancer: A retrospective analysis of patients supported with parenteral nutrition. Ann Oncol 2022. [DOI: 10.1016/j.annonc.2022.04.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Immunotherapy: Late Breaking Abstract: GENERATION OF DONOR-DERIVED MULTI-VIRUS SPECIFIC T CELLS (VST) TARGETING CYTOMEGALOVIRUS (CMV), EPSTEIN-BARR VIRUS (EBV), ADENOVIRUS, BK VIRUS AND SARS-COV2 TO PREVENT VIRAL INFECTION IN PATIENTS WITH SICKLE CELL DISEASE (SCD) AFTER BONE MARROW TRANSPLANT. Cytotherapy 2022. [DOI: 10.1016/s1465-3249(22)00360-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Nutritional autonomy in Short Bowel Syndrome and Intestinal Fistulas. Clin Nutr ESPEN 2022. [DOI: 10.1016/j.clnesp.2022.02.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Effect of Redosing Basiliximab in the Setting of Blood Loss in Heart Transplant Recipients on Infection and Rejection. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.01.1032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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POS-120 ROLE OF STEROIDS IN IGA NEPHROPATHY AND ITS CORRELATION TO HISTOPATHOLOGY. Kidney Int Rep 2022. [DOI: 10.1016/j.ekir.2022.01.132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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CT Evaluation of Hepatic Fat: A Novel Marker for High-Risk Coronary Atherosclerosis in Familial Hypercholesterolaemia. Heart Lung Circ 2022. [DOI: 10.1016/j.hlc.2022.06.240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Nutritional autonomy in short bowel syndrome and intestinal fistulas. Clin Nutr ESPEN 2021. [DOI: 10.1016/j.clnesp.2021.09.646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Tumor Volume Predicts for Pathological Complete Response in Rectal Cancer Patients Treated With Neoadjuvant Chemoradiation. Int J Radiat Oncol Biol Phys 2021. [DOI: 10.1016/j.ijrobp.2021.07.370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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455 A Case of An Unusual Penetrating Brain Injury. Br J Surg 2021. [DOI: 10.1093/bjs/znab259.290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Abstract
Introduction
Penetrating brain injuries (PBI) are less common than closed head traumas. Interest in frontal lobe injuries dates back to 1848’s famous Phineas Gage incident. Here, we report a case of a construction worker, who showed a remarkable neuropsychiatric outcome following a workplace accident.
Case Presentation
45year old gentleman came with complaint of a foreign body accidentally lodged in his forehead. He had no neurological deficits or CSF leak. X-ray revealed that a 5.5cm metallic screw was penetrating his skull, headfirst; CT revealed that approximately 3cm of the screw was in the frontal sinus. He was given antiepileptics and antibiotics prophylactically. Surgically the screw was removed by raising a bone flap and mobilizing the screw carefully by cutting the dura and adequate irrigation, causing minimal damage to the brain parenchyma. The dural deficits were repaired and the frontal sinus was canalized, then a drain was placed, and the patient was shifted to ICU for postoperative monitoring.
Discussion
It is important to prognosticate PBI as they can have neurological deficits that may be lifelong. Understanding the mechanism of injury, aggressive medical management and immediate surgical intervention may lead to improved outcomes. A foreign object of the size of 5.5cm, completely penetrating the skull would have otherwise resulted in extensive parenchymal damage. Literature suggests that no two people have an identical frontal sinus. In our patient the size the frontal sinus has served the purpose of protection against PBI and has resulted in minimal parenchymal injury (of only about 1cm).
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Drug-Polymer Interactions in Acetaminophen/Hydroxypropylmethylcellulose Acetyl Succinate Amorphous Solid Dispersions Revealed by Multidimensional Multinuclear Solid-State NMR Spectroscopy. Mol Pharm 2021; 18:3519-3531. [PMID: 34375100 PMCID: PMC8424625 DOI: 10.1021/acs.molpharmaceut.1c00427] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 07/22/2021] [Accepted: 07/23/2021] [Indexed: 02/08/2023]
Abstract
The bioavailability of insoluble crystalline active pharmaceutical ingredients (APIs) can be enhanced by formulation as amorphous solid dispersions (ASDs). One of the key factors of ASD stabilization is the formation of drug-polymer interactions at the molecular level. Here, we used a range of multidimensional and multinuclear nuclear magnetic resonance (NMR) experiments to identify these interactions in amorphous acetaminophen (paracetamol)/hydroxypropylmethylcellulose acetyl succinate (HPMC-AS) ASDs at various drug loadings. At low drug loading (<20 wt %), we showed that 1H-13C through-space heteronuclear correlation experiments identify proximity between aromatic protons in acetaminophen with cellulose backbone protons in HPMC-AS. We also show that 14N-1H heteronuclear multiple quantum coherence (HMQC) experiments are a powerful approach in probing spatial interactions in amorphous materials and establish the presence of hydrogen bonds (H-bond) between the amide nitrogen of acetaminophen with the cellulose ring methyl protons in these ASDs. In contrast, at higher drug loading (40 wt %), no acetaminophen/HPMC-AS spatial proximity was identified and domains of recrystallization of amorphous acetaminophen into its crystalline form I, the most thermodynamically stable polymorph, and form II are identified. These results provide atomic scale understanding of the interactions in the acetaminophen/HPMC-AS ASD occurring via H-bond interactions.
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PO-1420 iCARE: sarcoma patient radiotherapy experience during COVID-19. Radiother Oncol 2021. [PMCID: PMC8479300 DOI: 10.1016/s0167-8140(21)07871-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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PH-0331 Patterns And Predictors Of Relapse In Merkel Cell Carcinoma :Results From A Population Based Study. Radiother Oncol 2021. [DOI: 10.1016/s0167-8140(21)07304-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Provision of a local anaesthetic minor procedures service by surgical advanced clinical practitioners: 5-year study. BJS Open 2021; 5:6363073. [PMID: 34476465 PMCID: PMC8413366 DOI: 10.1093/bjsopen/zrab073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 07/09/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Surgical advanced clinical practitioners (SACPs) form part of the extended surgical workforce drawn from a variety of allied healthcare backgrounds. The primary aim of this study was to determine whether there was a financial benefit in having minor surgical procedures undertaken by dedicated SACPs compared with operating lists assigned to consultant surgeons. METHODS This was a retrospective cohort study including all patients who had minor 'lumps and bumps' procedures undertaken between April 2014 and August 2019 at East Lancashire Hospitals NHS Trust under local anaesthetic by the general surgery team. Clinical patient information, including lesion type, was collected along with operating room staffing levels and duration of operation. The cost of the procedure was calculated as operating time multiplied by cost of staff per minute according to local banding. RESULTS A total of 1399 patients had a lesion excised; 907 procedures were carried out by a doctor, and the rest independently by a SACP. The majority of lesions excised were lipomas and cysts. There was no difference in the median surgical time taken between SACPs and doctors (20 (i.q.r. 14-28) min). Minor procedures carried out on consultant surgeon lists cost 62.3 per cent (€25.33) more on average than those on SACP lists (median €65.96 versus 40.63 respectively; P < 0.001). CONCLUSION A dedicated and independent SACP 'lumps and bumps' list was financially beneficial. Operating times were similar to those of doctors. These lists safely free trainee and consultant surgeons to undertake more complex work.
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Value Of Atherosclerotic Plaque Characteristics And Pericoronary Adipose Tissue In Predicting Outcomes In Familial Hypercholesterolemia: Should CCTA Be Carried Out In All Adult Patients With FH? J Cardiovasc Comput Tomogr 2021. [DOI: 10.1016/j.jcct.2021.06.275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Can We Predict High-risk Plaques In Familial Hypercholesterolemia Using Clinical Variables And Coronary Artery Calcium. J Cardiovasc Comput Tomogr 2021. [DOI: 10.1016/j.jcct.2021.06.274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Limited utility of plasma elafin as a biomarker for skin graft-versus-host disease following allogeneic stem cell transplantation. Clin Exp Dermatol 2021; 46:1482-1487. [PMID: 34081805 DOI: 10.1111/ced.14785] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2021] [Indexed: 01/17/2023]
Abstract
BACKGROUND Acute cutaneous graft-versus-host disease (acGVHD) following haematopoietic stem cell transplant (HSCT) is common but difficult to distinguish from other causes of rash. Plasma elafin has been proposed as a diagnostic and prognostic biomarker of skin GVHD. AIM To evaluate the role of plasma elafin as a biomarker in acGVHD in an Indian population. METHODS Plasma elafin was evaluated in a prospective study of HSCT recipients, conducted over 2 years, taking measurements at baseline and at onset of skin rash after HSCT. Patients were categorized into those with GVHD rash, those with non-GVHD rash and those with no rash and the three groups were compared. RESULTS Two hundred and sixty-one patients with a median age of 16 years (range 1-61 years) and a male predominance (175 : 86 M/F) underwent HSCT during the study period: 56 patients in the GVHD group, 49 in the non-GVHD group and 156 in the no-rash group. The median baseline elafin was similar in all three groups. At the onset of rash, median elafin level was similar between GVHD and non-GVHD rash (34 549 vs. 32 077 pg/mL; P = 0.58) and between GVHD and no rash (34 549 vs. 26 197 pg/mL; P = 0.08). A rise in elafin from baseline was significantly different between GVHD and no rash (P < 0.001) but not between GVHD and non-GVHD rash (P = 0.44). CONCLUSION The utility of plasma elafin as a biomarker of skin GVHD is very limited. Plasma elafin, although elevated in cutaneous GVHD, is not helpful in distinguishing between GVHD rash and other causes of rash following HSCT.
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PROGNOSTIC SIGNIFICANCE OF TIME FROM LAST THERAPY IN PATIENTS WITH DIFFUSE LARGE B‐CELL LYMPHOMA: RETROSPECTIVE ANALYSIS OF ELECTRONIC HEALTH RECORDS AND CLAIMS DATA IN THE US. Hematol Oncol 2021. [DOI: 10.1002/hon.80_2880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Perinatal loss and parental loneliness: Narratives of late termination of pregnancy. DEATH STUDIES 2021; 46:1490-1500. [PMID: 33750278 DOI: 10.1080/07481187.2021.1894511] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Advances in perinatal medicine, present increasing numbers of women with difficult decisions about their pregnancy. We explored the views of 5 parents and 5 perinatal healthcare professionals regarding late termination of pregnancy following the principles of qualitative content analysis. Parents deciding on whether to (dis)continue pregnancy needed more time and decisional support. Decentralized care and lacking continuity between caregivers led to negative experiences. No standardized bereavement services were offered after leaving the hospital. Integrating principles of perinatal palliative care to care might help to offer further decisional support and to overcome the fragmentation of care.
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Analysis of biopharmaceutical formulations by Time Domain Nuclear Magnetic Resonance (TD-NMR) spectroscopy: A potential method for detection of counterfeit biologic pharmaceuticals. J Pharm Sci 2021; 110:2765-2770. [PMID: 33745914 DOI: 10.1016/j.xphs.2021.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 03/12/2021] [Accepted: 03/12/2021] [Indexed: 10/21/2022]
Abstract
1H Time-Domain Nuclear Magnetic Resonance (TD-NMR) is used to characterize solutions of antibodies that simulate biologic pharmaceutical formulations. The results from these measurements are compared with those from solutions in which the concentration or identity of the antibody has been altered. TD-NMR is shown to be very sensitive to differences in the amount of antibody in solution, with the ability to detect variations in as low as 2 mg/mL. It is therefore capable, by comparison with data from known formulations, of determining whether a particular sample is likely to be of an authentic biologic formulation. This method expands on the previous use of HPLC, UV/VIS, Near-IR and High-Resolution NMR to detect adulterated pharmaceutical materials. While the sensitivity of the method is high, it is a fingerprinting methodology, illustrating differences but not elucidating their origin. The extracted relaxation times reflect the combined effect of all solutes (antibody, buffer components, etc.) on the solvent (water).
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Value of Atherosclerotic Plaque Characteristics and Pericoronary Adipose Tissue in Predicting Outcomes in Familial Hypercholesterolaemia: Should CCTA be Carried out in all Adult Patients With FH? Heart Lung Circ 2021. [DOI: 10.1016/j.hlc.2021.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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OFP01.07 Delayed ALK Testing Results in the US - Analysis with a Large Real World Oncology Database. J Thorac Oncol 2021. [DOI: 10.1016/j.jtho.2020.10.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Can we Predict High-Risk Plaques in Familial Hypercholesterolaemia Using Clinical Variables and Coronary Artery Calcium? Heart Lung Circ 2021. [DOI: 10.1016/j.hlc.2021.06.190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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The accuracy of pre-operative (P)-POSSUM scoring and cardiopulmonary exercise testing in predicting morbidity and mortality after pancreatic and liver surgery: A systematic review. Ann Med Surg (Lond) 2020; 62:1-9. [PMID: 33489107 PMCID: PMC7804364 DOI: 10.1016/j.amsu.2020.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 12/08/2020] [Accepted: 12/10/2020] [Indexed: 11/10/2022] Open
Abstract
Background Cardiopulmonary exercise-testing (CPET) and the (Portsmouth) Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity ((P)-POSSUM) are used as pre-operative risk stratification and audit tools in general surgery, however, both have been demonstrated to have limitations in major hepatopancreatobiliary (HPB) surgery. Materials and methods The aim of this review is to determine if CPET and (P)-POSSUM scoring systems accurately predict morbidity and mortality. Eligible articles were identified with an electronic database search. Analysis according to surgery type and tool used was performed. Results Twenty-five studies were included in the final review. POSSUM predicted morbidity demonstrated weighted O/E ratios of 0.75(95%CI0.57–0.97) in hepatic surgery and 0.85(95%CI0.8–0.9) in pancreatic surgery. P-POSSUM predicted mortality in pancreatic surgery demonstrated an O/E ratio of 0.75(95%CI0.27–2.13) and 0.94(95%CI0.57–1.55) in hepatic surgery. In both pancreatic and hepatic surgery an anaerobic threshold(AT) of between 9 0.5–11.5 ml/kg/min was predictive of post-operative complications, and in pancreatic surgery ventilatory equivalence of carbon dioxide(˙VE/˙VCO2) was predictive of 30-day mortality. Conclusion POSSUM demonstrates an overall lack of predictive fit for morbidity, whilst CPET variables provide some predictive power for post-operative outcomes. Development of a new HPB specific risk prediction tool would be beneficial; the combination of parameters from POSSUM and CPET, alongside HPB specific markers could overcome current limitations. Current pre-operative scoring for pancreatic and liver surgery is inaccurate. In pancreatic and liver surgery anaerobic threshold scores were predictive of complications. In pancreatic surgery ventilatory equivalence of carbon dioxide was predictive of mortality. P-POSSUM is inaccurate for predicting mortality and morbidity in pancreatic surgery.
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An Under-Appreciated Source of Reproducibility Issues in Cross-Coupling: Solid-State Decomposition of Primary Sodium Alkoxides in Air. ACS Catal 2020. [DOI: 10.1021/acscatal.0c04124] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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33
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The occurrence of chronic kidney disease in patients on long-term home parenteral nutrition. Clin Nutr ESPEN 2020. [DOI: 10.1016/j.clnesp.2020.09.348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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34
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Outcomes associated with strong opioid use for non-cancer pain in patients with chronic intestinal failure. Clin Nutr ESPEN 2020. [DOI: 10.1016/j.clnesp.2020.09.342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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35
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Factors affecting antidepressant use by patients requiring home parenteral nutrition. Clin Nutr ESPEN 2020. [DOI: 10.1016/j.clnesp.2020.09.341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Advances of solid-state NMR spectroscopy in material sciences. MAGNETIC RESONANCE IN CHEMISTRY : MRC 2020; 58:987. [PMID: 33006157 DOI: 10.1002/mrc.5086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 08/04/2020] [Indexed: 06/11/2023]
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Solid state nuclear magnetic resonance studies of hydroxypropylmethylcellulose acetyl succinate polymer, a useful carrier in pharmaceutical solid dispersions. MAGNETIC RESONANCE IN CHEMISTRY : MRC 2020; 58:1036-1048. [PMID: 31880823 DOI: 10.1002/mrc.4984] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 11/19/2019] [Accepted: 12/16/2019] [Indexed: 06/10/2023]
Abstract
Hydroxypropylmethylcellulose (HPMC) acetyl succinate (HPMC-AS) is a key polymer used for the enablement of amorphous solid dispersions (ASDs) in oral solid dosage forms. Choice of the appropriate grade within the material is often made empirically by the manufacturer of small-scale formulations, followed by extensive real time stability. A key factor in understanding and predicting the performance of an ASD is related to the presence of hydrogen (or other) bonds between the polymer and active pharmaceutical ingredient (API), which will increase stability over the parameters captured by miscibility and predicted by the Gordon-Taylor equation. Solid state nuclear magnetic resonance (NMR) is particularly well equipped to probe spatial proximities, for example, between polymer and API; however, in the case of HPMC-AS, these interactions have been sometimes difficult to identity as the carbon-13 NMR spectra assignment is yet to be firmly established. Using feedstock, selectively substituted HPMC polymers, and NMR editing experiments, we propose here a comprehensive understanding of the chemical structure of HPMC-AS and a definitive spectral assignment of the 13 C NMR spectra of this polymer. The NMR data also capture the molar ratios of the acetate and succinate moieties present in HPMC-AS of various grades without the need for post treatment required by chromatography methods commonly use in pharmacopoeia. This knowledge will allow the prediction and measurement of interactions between polymers and APIs and therefore a rational choice of polymer grade to enhance the solid state stability of ASDs.
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Intraductal Papillary Adenocarcinoma Of The Bile Duct With Associated Invasive Neuroendocrine Component: Case Report. Am J Clin Pathol 2020. [DOI: 10.1093/ajcp/aqaa161.148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Casestudy
Intraductal papillary neoplasm of the bile duct (IPNB) is a variant of bile duct carcinoma that is characterized by intraductal growth and better outcomes compared with common cholangiocarcinoma. IPNBs are mainly found in patients from Far Eastern countries, where hepatolithiasis and clonorchiasis are endemic.
Approximately 40%-80% of IPNBs are associated with invasive carcinoma. The invasive carcinomas are most often tubular or mucinous type. Invasive neuroendocrine component has not been previously described.
We present a case of 69 year-old African American male who presented with worsening abdominal pain and jaundice over few months. Computed tomography showed 4 cm mass near the porta hepatis with massive ductal dilatation. A fine needle aspiration of the mass was performed and a diagnosis of adenocarcinoma was made. Subsequently, the patient underwent Right Trisegmentectomy.
Conclusion
Histologic sections revealed intraductal papillary neoplasm in the bile duct lumina. The papillae were lined by columnar epithelial cells with delicate fibrovascular cores. The tumor cell nuclei were slightly elongated, hyperchromatic and basally located without significant multilayering. The cytoplasm was eosinophilic with occasional intestinal differentiation. Frank invasion of the stalk and underlying periductular tissues was identified. Interestingly; the invasive component had different cytological features than the intraductal component, it was composed of small to medium sized cells with granular cytoplasm. The nuclei were uniform and round with “salt and pepper” chromatin. The invasive component stained positively for the neuroendocrine markers (Synaptophysin, Chromogranin and CD56), whereas the intraductal component stained positively for CK7, CK20 and CDX2 and negative for neuroendocrine markers.
Three years later, a recurrent tumor was found in the left lobe on imaging. Biopsy of the lesion showed metastatic neuroendocrine carcinoma. The intraductal papillary neoplasm with invasive neuroendocrine component is very unusual tumor, we think more studies are warranted to best evaluate the treatment options and the prognosis of such neoplasms.
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Abstract
The objective of this study was to understand the impact of coating excipients on the chemical stability of active pan coated peliglitazar, which was prone to acid as well as base-catalyzed degradation. Four different coating formulations containing either polyvinyl alcohol (PVA) or hydroxypropyl methylcellulose (HPMC) as a coating polymer and triacetin (glycerol triacetate) or polyethylene glycol (PEG) as a plasticizer/detackifier were used for coating of peliglitazar in a perforated pan coater. Tablets of one-milligram strength were manufactured by suspending the drug in the coating suspension and spray coating onto inert core tablets. The active coated tablets were placed on stability (40 °C/75% RH) in high-density polyethylene (HDPE) bottles in closed condition with desiccants or in open condition. Tablet samples were withdrawn and analyzed for degradants using a stability-indicating HPLC method. The overall stability for the film-forming polymer-plasticizer/detackifier combination showed the rank order: HPMC-triacetin > PVA-triacetin > HPMC-PEG > PVA-PEG. Higher stability of triacetin systems over PEG systems was attributed to lower solubility of peliglitazar in triacetin coating systems. For the same plasticizer/detackifier, higher stability of HPMC over PVA-based formulations was attributed to lower solubility and mobility of peliglitazar in HPMC compared with the PVA-based coating.
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Characterization of a novel enzyme from Photobacterium phosphoreum with histidine decarboxylase activity. Int J Food Microbiol 2020; 334:108815. [PMID: 32966918 DOI: 10.1016/j.ijfoodmicro.2020.108815] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 05/01/2020] [Accepted: 08/02/2020] [Indexed: 11/16/2022]
Abstract
Histamine or scombrotoxin fish poisoning is caused by ingestion of bacterially produced histamine in fish. Histamine-producing bacteria generally contain the histidine decarboxylase gene (hdc). However, some strains of Photobacterium phosphoreum are known to produce significant levels of histamine, although the hdc gene in these strains has not been recognized. The objective of this study was to investigate a previously unidentified mechanism of histamine production by P. phosphoreum. We identified a protein with histidine decarboxylase (HDC) activity comparable to activity of the pyridoxal-5-phosphate (PLP) dependent HDC from P. kishitanii and M. morganii. The newly identified protein (HDC2) in P. phosphoreum and P. kishitanii strains, was approximately 2× longer than the HDC protein from other Gram-negative bacteria and had 12% similarity to previously identified HDCs. In addition, the hdc2 gene cluster in P. phosphoreum was identical to the hdc gene cluster in P. kishitanii. HDC2 had optimal activity at 20-35 °C, at pH 4, and was not affected by 0-8% NaCl concentrations. Compared to the hdc gene from P. kishitanii, expression of the hdc2 gene was constitutive and not affected by pH or excess histidine. This newly identified protein explains possible mechanisms of histamine production in P. phosphoreum. Characterization of this protein will help in designing control measures to prevent or reduce histamine production in fish.
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Home parenteral nutrition and the older adult: Experience from a national intestinal failure unit. Clin Nutr 2020; 39:1418-1422. [DOI: 10.1016/j.clnu.2019.06.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 06/19/2019] [Accepted: 06/22/2019] [Indexed: 12/18/2022]
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Fast understanding of phases and phase separation in liquid crystal drug delivery systems using deuterium solid-state NMR. SOLID STATE NUCLEAR MAGNETIC RESONANCE 2020; 106:101642. [PMID: 32035327 DOI: 10.1016/j.ssnmr.2020.101642] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 01/02/2020] [Accepted: 01/06/2020] [Indexed: 06/10/2023]
Abstract
Characterization of lipid based (SPC/GDO/H2O) liquid crystal (LC) drug delivery system is non-trivial and highly complex, especially when multiple and intermediate phases are present. The phase behavior of such mixtures during hydration or delivery is still poorly understood and therefore, characterizing these systems is crucially important towards controlling their function and enhancing the understanding of their drug release behavior. Current work has established an easy way to identify liquid crystal phases and phase mixtures using deuterium (2H) solid-state nuclear magnetic (NMR) spectroscopy under static conditions without disrupting the three dimensional structure and phases, as magic-angle spinning (MAS) could lead to disruption of the phases. Small angle X-ray scattering (SAXS) technique and optical microscopy were also employed to corroborate the study.
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169 COMP-4 Reduces Oxidative Stress Markers in the Rat Corpora Cavernosa and Media of the Penile Dorsal Artery. J Sex Med 2020. [DOI: 10.1016/j.jsxm.2019.11.115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Treating complexity in the older adult - the role of the geriatric giants. S Afr Fam Pract (2004) 2019. [DOI: 10.4102/safp.v61i6.5065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
As people age, they accumulate medical conditions. Geriatric giants comprise a group of conditions that lead to significant mortality and morbidity and contribute to the complexity in treating geriatric patients. They are common and rarely occur in isolation. The 5 Is of geriatric giants are: iatrogenesis, immobility, instability, incontinence and impaired cognition. Consequences for the patient and their caregivers include loss of functional independence, institutionalisation and caregiver burnout. Primary care practitioners are often the first port of call for geriatric patients in South Africa and by asking a few key questions and performing a thorough examination; these conditions can be recognised early. Whilst there are often limitations to cure, the main aim is to maintain the older adult’s functional independence as much as possible, and by following an organised management approach to each of these conditions, the quality of life of patients can be improved.
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Burning Feet, Dilated Heart and Failed Kidneys. Indian J Nephrol 2019; 29:357-359. [PMID: 31571744 PMCID: PMC6755931 DOI: 10.4103/ijn.ijn_35_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Fabry's disease, X-linked lysosomal storage disease, results from deficient activity of alpha galactosidaseA (α-GalA). Renal manifestation usually begins at third decade of life. We report a 16 year male with initial presentation with end stage renal disease (ESRD) and the diagnosis confirmed by presence of myeloid bodies on electron microscopy of kidney biopsy and low serum α-GalA level.
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A novel vaccine platform using glucan particles for induction of protective responses against Francisella tularensis and other pathogens. Clin Exp Immunol 2019; 198:143-152. [PMID: 31400225 PMCID: PMC6797901 DOI: 10.1111/cei.13356] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2019] [Indexed: 12/13/2022] Open
Abstract
Vaccines are considered the bedrock of preventive medicine. However, for many pathogens, it has been challenging to develop vaccines that stimulate protective, long-lasting immunity. We have developed a novel approach using β-1,3-D-glucans (BGs), natural polysaccharides abundantly present in fungal cell walls, as a biomaterial platform for vaccine delivery. BGs simultaneously provide for receptor-targeted antigen delivery to specialized antigen-presenting cells together with adjuvant properties to stimulate antigen-specific and trained non-specific immune responses. This review focuses on various approaches of using BG particles (GPs) to develop bacterial and fungal vaccine candidates. A special case history for the development of an effective GP tularaemia vaccine candidate is highlighted.
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Chronic stress, depression and personality type in patients with myasthenia gravis. Eur J Neurol 2019; 27:204-209. [PMID: 31408565 DOI: 10.1111/ene.14057] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 08/05/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE Stress is a known risk factor for the onset and modulation of disease activity in autoimmune disorders. The aim of this cross-sectional study was to determine any associations between myasthenia gravis (MG) severity and chronic stress, depression and personality type. METHODS In all, 179 consecutive adult patients with confirmed MG attending the Neuromuscular Clinic between March 2017 and December 2017 were included. At baseline, patients were assessed clinically and they completed self-administered scales for disease severity, perceived stress, depression and personality type. RESULTS Higher disease severity [Myasthenia Gravis Impairment Index (MGII)] showed a moderate correlation with depression score (Beck's Depression Inventory, Second Edition, r = 0.52, P < 0.001) and a lower correlation with chronic stress (Trier Inventory for Assessment of Chronic Stress, r = 0.28, P = 0.001). Chronic stress scores were different according to personality types (anova, P = 0.02). The linear regression model with MGII score as the dependent variable showed R2 = 0.34, likelihood ratio chi-squared 74.55, with P < 0.0001. The only variables that predicted disease severity were depression scores (P < 0.0001) and female sex (P = 0.003). CONCLUSIONS A significant association of MG severity with depression and chronic stress was found, as well as with female gender. These findings should raise awareness that the long-term management of MG should address depression and potential stress and consider behavioural management to prevent stress-related immune imbalance.
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SUN-PO262: Sensitivity of Differential Time to Positivity Compared to Pour Plates for Diagnosing Catheter-Related Blood Stream Infection: An Evaluation in Patients with Chronic Intestinal Failure. Clin Nutr 2019. [DOI: 10.1016/s0261-5614(19)32892-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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SUN-PO263: Are Femoral Tunnelled Central Venous Catheters Safe to use for HPN? Clin Nutr 2019. [DOI: 10.1016/s0261-5614(19)32893-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Stage Migration in Cervical Cancer Using the FIGO 2018 Staging System: A Retrospective Survival Analysis Using a Single Institution Patient Cohort. Is There a Will Rogers Phenomenon? Int J Radiat Oncol Biol Phys 2019. [DOI: 10.1016/j.ijrobp.2019.06.1742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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