Treatment with lamivudine, zidovudine, or both in HIV-positive patients with 200 to 500 CD4+ cells per cubic millimeter. North American HIV Working Party

BACKGROUND

The reverse-transcriptase inhibitor lamivudine has in vitro synergy with zidovudine against the human immunodeficiency virus (HIV). We studied the activity and safety of lamivudine plus zidovudine as compared with either drug alone as treatment for patients with HIV infection, most of whom had not previously received zidovudine.

METHODS

Three hundred sixty-six patients with 200 to 500 CD4+ cells per cubic millimeter who had received zidovudine for four weeks or less were randomly assigned to treatment with one of four regimens: 300 mg of lamivudine every 12 hours; 200 mg of zidovudine every 8 hours; 150 mg of lamivudine every 12 hours plus zidovudine; or 300 mg of lamivudine every 12 hours plus zidovudine. The study was double-blind and lasted 24 weeks, with an extension phase for another 28 weeks.

RESULTS

Over the 24-week period, the low-dose and high-dose regimens combining lamivudine and zidovudine were associated with greater increases in the CD4+ cell count (P = 0.002 and P = 0.015, respectively) and the percentage of CD4+ cells (P < 0.001 for both) and with greater decreases in plasma levels of HIV-1 RNA (P < 0.001 for both) than was treatment with zidovudine alone. Combination therapy was also more effective than lamivudine alone in lowering plasma HIV-1 RNA levels and increasing the percentage of CD4+ cells (P < 0.001 for all comparisons), and these advantages persisted through 52 weeks. Adverse events were no more frequent with combination therapy than with zidovudine alone.

CONCLUSIONS

In HIV-infected patients with little or no prior antiretroviral therapy, treatment with a combination of lamivudine and zidovudine is well tolerated over a one-year period and produces more improvement in immunologic and virologic measures than does treatment with either agent alone.

A comparison of stavudine plus lamivudine versus zidovudine plus lamivudine in combination with indinavir in antiretroviral naive individuals with HIV infection: selection of thymidine analog regimen therapy (START I)

BACKGROUND

No clinical trial results directly comparing two nucleoside analog pairs in a drug regimen for HIV that includes a protease inhibitor are available.

OBJECTIVE

To compare the safety and efficacy of stavudine (d4T) + lamivudine (3TC) with zidovudine (ZDV) + 3TC, each in combination with indinavir (IDV).

DESIGN

Randomized, open-label, multi-center.

SETTING

Fifteen HIV clinical research centers.

PATIENTS

Two-hundred and four antiretroviral-naive HIV-1-infected-patients with CD4 cell counts > or = 200 x 10(6)/l and HIV-1 RNA > or = 10,000 copies/ml (bDNA assay), modified to 5000 copies/ml.

INTERVENTION

d4T 40 mg twice a day, 3TC 150 mg twice a day plus IDV 800 mg every 8 h compared with ZDV 200 mg every 8 h (modified to 300 mg every 12 h) plus 3TC and IDV.

MEASUREMENTS

Primary endpoint: plasma HIV-1 RNA < 500 copies/ml. Additional endpoints: HIV-1 RNA < or = 50 copies/ml; change from baseline in HIV-1 RNA and CD4 cell counts; safety and adverse events.

RESULTS

For HIV-1 RNA, 62% of patients on d4T + 3TC + IDV and 54% of patients on ZDV + 3TC + IDV had < 500 copies/ml HIV RNA at weeks 40 through 48 [90% confidence interval, -0.204 to 0.036; P= 0.213], with 49% and 47% respectively achieving < or = 50 copies/ml at 48 weeks (90% CI, -0.134 to 0.096; P = 0.834). Median change in CD4 cell counts at 48 weeks was +227 x 10(6)/l and +198 x 10(6)/l for the d4T- and ZDV-containing arms, respectively. The median time-weighted average change from baseline in CD4 cell counts was significantly greater at 48 weeks in the d4T-containing arm (142 x 10(6)/l versus 110 x 10(6)/l; P = 0.033). Serious adverse events were not significantly different between treatment arms, but there were significant differences for frequency of adverse events of all severity with increased nausea and vomiting in the ZDV-containing arm, and increased diarrhea and rash in the d4T-containing arm.

CONCLUSIONS

These results support the choice of d4T + 3TC as a nucleoside analog pair in combination with a protease inhibitor in an initial HIV treatment regimen.

Simultaneous quantitation of intracellular zidovudine and lamivudine triphosphates in human immunodeficiency virus-infected individuals

Highly active antiretroviral therapy (HAART) is the standard treatment for infection with human immunodeficiency virus (HIV). The most common HAART regimen consists of the combination of at least one protease inhibitor (PI) with two nucleoside reverse transcriptase inhibitors (NRTIs). Contrary to PIs, NRTIs require intracellular activation from the parent compound of their triphosphate moiety to suppress HIV replication. Simultaneous intracellular determination of two NRTI triphosphates is difficult to accomplish due to their relatively small concentrations in peripheral blood mononuclear cells (PBMCs), requiring large amounts of blood from HIV-positive patients. Recently, we described a method to determine intracellular zidovudine triphosphate (ZDV-TP) concentrations in HIV-infected patients by using solid-phase extraction and tandem mass spectrometry. The limit of quantitation (LOQ) for ZDV-TP was 0.10 pmol, and the method was successfully used for the determination of ZDV-TP in HIV-positive patients. In this study, we enhanced the aforementioned method by the simultaneous quantitation of ZDV-TP and lamivudine triphosphate (3TC-TP) in PBMCs from HIV-infected patients. The LOQ for 3TC-TP was 4.0 pmol, with an interassay coefficient of variation and an accuracy of 7 and 12%, respectively. This method was successfully applied to the simultaneous in vivo determination of the ZDV-TP and 3TC-TP pharmacokinetic profiles from HIV-infected patients receiving HAART.

Determination of zidovudine triphosphate intracellular concentrations in peripheral blood mononuclear cells from human immunodeficiency virus-infected individuals by tandem mass spectrometry

Nucleoside reverse transcriptase inhibitors (NRTIs) used against the human immunodeficiency virus (HIV) need to be activated intracellularly to their triphosphate moiety to inhibit HIV replication. Intracellular concentrations of these NRTI triphosphates, especially zidovudine triphosphate (ZDV-TP), are relatively low (low numbers of femtomoles per 10(6) cells) in HIV-infected patient peripheral blood mononuclear cells. Recently, several methods have used either high-performance liquid chromatography (HPLC) or solid-phase extraction (SPE) coupled with radioimmunoassay to obtain in vivo measurements of ZDV-TP. The limit of detection (LOD) by these methods ranged from 20 to 200 fmol/10(6) cells. In this report, we describe the development of a method to determine intracellular ZDV-TP concentrations in HIV-infected patients using SPE and HPLC with tandem mass spectrometry for analysis. The LOD by this method is 4.0 fmol/10(6) cells with a linear concentration range of at least 4 orders of magnitude from 4. 0 to 10,000 fmol/10(6) cells. In hispanic HIV-infected patients, ZDV-TP was detectable even when the sampling time after drug administration was 15 h. Intracellular ZDV-TP concentrations in these patients ranged from 41 to 193 fmol/10(6) cells. The low LOD obtained with this method will provide the opportunity for further in vivo pharmacokinetic studies of intracellular ZDV-TP in different HIV-infected populations. Furthermore, this methodology could be used to perform simultaneous detection of two or more NRTIs, such as ZDV-TP and lamivudine triphosphate.

Involvement of calyculin A-sensitive phosphatase(s) in the differentiation of Trypanosoma cruzi trypomastigotes to amastigotes

Differentiation of the non-dividing trypomastigote form of Trypanosoma cruzi, the causative agent of Chagas disease, to the dividing amastigote form normally occurs in cytoplasm of infected cells. Here we show that calyculin A. a potent inhibitor of protein phosphatases 1 and 2A, induces at pH 7.5 extracellular transformation of long slender trypomastigotes to round amastigote-like forms which acquire characteristic features observed after the normal differentiation process: repositioning and structural changes of the kinetoplast, release of surface neuraminidase, and expression of amastigote-specific epitopes. Calyculin A inhibits parasite phosphatases and changes in the phosphorylation of specific proteins occur during the transformation process. As an exposure of trypomastigotes to calyculin A concentrations as low as 1 nM and for only 1-2 h is sufficient to induce transformation, the inhibition of calyculin A-sensitive phosphatase(s) appears to play a major role in initiating the trypomastigote differentiation.

Synthesis and activity of pyrrolidinyl- and thiazolidinyl-dipeptide derivatives as inhibitors of the Tc80 prolyl oligopeptidase from Trypanosoma cruzi

Pyrrolidinyl- and thiazolidinyl- dipeptide derivatives, featuring either a vinyl sulfone-, a 2-ketobenzothiazole-, a nitrile-, or a benzimidazole group at the C-terminus, were designed and synthesized as potential inhibitors of the prolyl-specific Tc80 proteinase from Trypanosoma cruzi, the agent of Chagas' disease. These compounds were evaluated in vitro towards the target enzyme which was classified as a serine protease belonging to the prolyl oligopeptidase family (EC 3.4.21.26). A peptidyl nitrile and two peptidyl alpha-ketobenzothiazoles were shown to be potent reversible and competitive inhibitors of Tc 80 proteinase, with K(i) values in the range 38-219 nM, and compared advantageously with some known mammalian prolyl oligopeptidase inhibitors.

Identification of inhibitors of an 80 kDa protease from Trypanosoma cruzi through the screening of a combinatorial peptide library

Two orthogonal peptide combinatorial libraries were screened to discover inhibitors of Tc80 protease, a novel target from Trypanosoma cruzi involved in host cell invasion. These libraries were composed of 15,625 structurally diversified tripeptides, partitioned in 125 mixtures. The screening led to a low micromolar inhibitor which was actually an HF cleavage by-product H-Ipe-D-Tic-D-Glu(S-paratolyl)-OH. IC50 values of several analogous molecules of this hit were determined and are discussed. For the best compounds, conformational analysis revealed a high degree of similarity in shape with a potent prolylendopeptidase inhibitor, SUAM-1221.

Efficacy and Safety of Ensovibep for Adults Hospitalized With COVID-19 : A Randomized Controlled Trial

BACKGROUND

Ensovibep (MP0420) is a designed ankyrin repeat protein, a novel class of engineered proteins, under investigation as a treatment of SARS-CoV-2 infection.

OBJECTIVE

To investigate if ensovibep, in addition to remdesivir and other standard care, improves clinical outcomes among patients hospitalized with COVID-19 compared with standard care alone.

DESIGN

Double-blind, randomized, placebo-controlled, clinical trial. (ClinicalTrials.gov: NCT04501978).

SETTING

Multinational, multicenter trial.

PARTICIPANTS

Adults hospitalized with COVID-19.

INTERVENTION

Intravenous ensovibep, 600 mg, or placebo.

MEASUREMENTS

Ensovibep was assessed for early futility on the basis of pulmonary ordinal scores at day 5. The primary outcome was time to sustained recovery through day 90, defined as 14 consecutive days at home or place of usual residence after hospital discharge. A composite safety outcome that included death, serious adverse events, end-organ disease, and serious infections was assessed through day 90.

RESULTS

An independent data and safety monitoring board recommended that enrollment be halted for early futility after 485 patients were randomly assigned and received an infusion of ensovibep (n = 247) or placebo (n = 238). The odds ratio (OR) for a more favorable pulmonary outcome in the ensovibep (vs. placebo) group at day 5 was 0.93 (95% CI, 0.67 to 1.30; P = 0.68; OR > 1 would favor ensovibep). The 90-day cumulative incidence of sustained recovery was 82% for ensovibep and 80% for placebo (subhazard ratio [sHR], 1.06 [CI, 0.88 to 1.28]; sHR > 1 would favor ensovibep). The primary composite safety outcome at day 90 occurred in 78 ensovibep participants (32%) and 70 placebo participants (29%) (HR, 1.07 [CI, 0.77 to 1.47]; HR < 1 would favor ensovibep).

LIMITATION

The trial was prematurely stopped because of futility, limiting power for the primary outcome.

CONCLUSION

Compared with placebo, ensovibep did not improve clinical outcomes for hospitalized participants with COVID-19 receiving standard care, including remdesivir; no safety concerns were identified.

PRIMARY FUNDING SOURCE

National Institutes of Health.

Local control with pre-operative radiotherapy alone versus "sandwich" radiotherapy for rectal carcinoma

Forty-nine patients with primary adenocarcinoma of the rectum, clinically localized to the pelvis were treated with pre-op radiotherapy (RT) 1500 cGy/5 fx with AP/PA fields, followed by immediate curative resection. Patients staged as Astler-Coller B2, C1, or C2 were considered for post-op RT, 4140 cGy/23 fxs with a 4-field technique. There were 47 evaluable patients in this non-randomized study. Two groups of patients were analyzed, namely pre-op RT only (24 patients) and combined pre- and post-op ("sandwich") RT (23 patients). Two patients with pre-op RT only were considered inevaluable for recurrence because they died NED at 1 and 7 mo. All patients have been followed for greater than 1 year; 77% have been followed for greater than 2 yr. There has been only one local recurrence (LR), surprisingly in a Stage A pre-op RT patient who had no residual tumor in the final operative specimen. In the pre-op group which included 10 B2s, and 1 C2, 1500 cGy in 5 days (equivalent to 1940 cGy by the NSD formulation) was associated with no local recurrence. No distant metastases (DM) have developed in this group. In the "sandwich" RT group, which included 3 B2s, 1 C1, 17 C2s, and 1 D (localized to the pelvis, i.e. ovary), there were no LRs and 7 DMs (1 B2 and 6 C2s). Actuarial survival is 92% in the pre-op RT group at 2 and 3 yr, and 82% in the "sandwich" group at 2 and 3 yr. There have been no serious early or late complications related to RT in our pre-op group. The use of 1500 cGy in 5 days as pre-op RT with immediate surgery may prove, upon longer follow-up, to be sufficient for increasing local control, with minimum morbidity, in patients with B2 disease. Patients with C2 disease are being controlled locally with the "sandwich" regimen, but it is not clear whether pre-op RT alone may be adequate in this group as well. We are now addressing this question in a randomized study.

Molecular MRI of the Immuno-Metabolic Interplay in a Rabbit Liver Tumor Model: A Biomarker for Resistance Mechanisms in Tumor-targeted Therapy?

Background The immuno-metabolic interplay has gained interest for determining and targeting immunosuppressive tumor micro-environments that remain a barrier to current immuno-oncologic therapies in hepatocellular carcinoma. Purpose To develop molecular MRI tools to reveal resistance mechanisms to immuno-oncologic therapies caused by the immuno-metabolic interplay in a translational liver cancer model. Materials and Methods A total of 21 VX2 liver tumor-bearing New Zealand white rabbits were used between October 2018 and February 2020. Rabbits were divided into three groups. Group A (n = 3) underwent intra-arterial infusion of gadolinium 160 (160Gd)-labeled anti-human leukocyte antigen-DR isotope (HLA-DR) antibodies to detect antigen-presenting immune cells. Group B (n = 3) received rhodamine-conjugated superparamagnetic iron oxide nanoparticles (SPIONs) intravenously to detect macrophages. These six rabbits underwent 3-T MRI, including T1- and T2-weighted imaging, before and 24 hours after contrast material administration. Group C (n = 15) underwent extracellular pH mapping with use of MR spectroscopy. Of those 15 rabbits, six underwent conventional transarterial chemoembolization (TACE), four underwent conventional TACE with extracellular pH-buffering bicarbonate, and five served as untreated controls. MRI signal intensity distribution was validated by using immunohistochemistry staining of HLA-DR and CD11b, Prussian blue iron staining, fluorescence microscopy of rhodamine, and imaging mass cytometry (IMC) of gadolinium. Statistical analysis included Mann-Whitney U and Kruskal-Wallis tests. Results T1-weighted MRI with 160Gd-labeled antibodies revealed localized peritumoral ring enhancement, which corresponded to gadolinium distribution detected with IMC. T2-weighted MRI with SPIONs showed curvilinear signal intensity representing selective peritumoral deposition in macrophages. Extracellular pH-specific MR spectroscopy of untreated liver tumors showed acidosis (mean extracellular pH, 6.78 ± 0.09) compared with liver parenchyma (mean extracellular pH, 7.18 ± 0.03) (P = .008) and peritumoral immune cell exclusion. Normalization of tumor extracellular pH (mean, 6.96 ± 0.05; P = .02) using bicarbonate during TACE increased peri- and intratumoral immune cell infiltration (P = .002). Conclusion MRI in a rabbit liver tumor model was used to visualize resistance mechanisms mediated by the immuno-metabolic interplay that inform susceptibility and response to immuno-oncologic therapies, providing a therapeutic strategy to restore immune permissiveness in liver cancer. © RSNA, 2020 Online supplemental material is available for this article.

Clinical effect of a Mexican sanguinaria extract (Polygonum aviculare L.) on gingivitis

It is well known that gingivitis is a bacterially-elicited inflammation of the marginal gingiva. A number of chemical agents have been evaluated over the years with regard to their antimicrobial effects in the oral cavity; however, all are associated with side effects that prohibit regular long-term use. Therefore, the effectiveness of a natural Mexican Sanguinaria extract (Polygonum aviculare L.) against gingivitis, was assessed in 60 male dentistry students between the ages of 18 and 25 years. Over a period of 2 weeks, these students used the Sanguinaria extract (1 mg/ml) in oral rinse twice daily as a unique oral health measurement (no tooth-brushing was allowed). The O'Leary Plaque Index and the Löe and Silness Gingivitis Index were recorded at baseline (day 0) in all the subjects. Also, a complete prophylaxis was performed after both indices were obtained. The antibacterial and antiinflammatory effects of the extract were evaluated on days 7, 11 and 14. The results showed that the Mexican Sanguinaria extract in oral rinse significantly decreased gingivitis from day 0 (-x=1. 056) to day 14 (-x=1.011) (P</=0.05). In contrast, a significant increase in dental plaque was observed from day 0 (-x=91.38) to day 14 (-x=98.69) (P</=0.05); however, the consistency of this plaque permitted its mechanical flushing easily. From this study, it is concluded that the Mexican Sanguinaria extract in oral rinse can be employed supportively in the therapy of gingivitis.

Step by step optimization of a sperm cryopreservation protocol for spotted wolffish (Anarhichas minor Olafsen, 1772)

Spotted wolffish Anarhichas minor reproduction in captivity is dependent on in vitro fertilization. However, low sperm volume with relatively low cell concentration and the lack of gametes synchronization (simultaneous availability of mature eggs and sperm) represent a challenge for the industry. Thus, the development of protocols for sperm storage are crucial. Four sequential experiments were conducted to optimize a sperm cryopreservation protocol for this species. First, three different cryoprotectants (DMSO; 1, 2-propanediol; and methanol) at different concentrations (5, 10, and 20%) were tested for their toxicity. No significant differences (p > 0.05) were detected between the control samples and cryoprotectants at concentration up to 10% DMSO, 10% propanediol, and 20% methanol in terms of motility parameters. Second, using the highest non-toxic concentrations of cryoprotectants, sperm was cryopreserved in 0.5 mL straws, at different distances from the liquid nitrogen (1.5, 2.5, 4.5, and 7.5 cm) that correspond to different freezing rates. Motility parameters after freezing/thawing decreased for all the cryoprotectants (p < 0.001), however, methanol had the lowest protective capacity while DMSO the highest. Afterwards, two different thawing rates (1 min at 5 °C; and 25 s at 10 °C) were tested using only 10% DMSO and 10% propanediol. Both for the DMSO and propanediol, there were no significant differences (p > 0.05) between the two thawing rates. The best results were obtained using 10% DMSO. Finally, the fertilization capacity of cryopreserved sperm (10% DMSO and thawed at 5 °C for 1 min) was tested against fresh sperm using two spermatozoa:egg ratios and 4 h gametes contact time. The ratio of eggs with normal cell cleavage, abnormal cleavage or undeveloped were counted at the 2-4 cell stage. Cryopreserved sperm showed lower fertilization capacity at a concentration of 5 × 10⁴ spermatozoa:egg compared with fresh sperm (p < 0.001). At a concentration of 5 × 10⁵ spermatozoa:egg, similar fertilizations rates to the fresh sperm were obtained. The presence of the cryoprotectant DMSO during the 4 h contact time did not affect the fertilization rate or the percentage of embryos with abnormal cleavage (p > 0.05). To cryopreserve spotted wolffish sperm it is recommended to use 10% DMSO, loaded in 0.5 mL straws, freeze at a height between 4.5 (-14.05 °C/min) and 7.5 cm (-5.9 °C/min) from liquid nitrogen for 10 min and thaw for 1 min at 5 °C (177.9 °C/min). In vitro fertilization with cryopreserved sperm should be performed with a concentration of at least 5 × 10⁵ spermatozoa per egg.

Reticular erythematous mucinosis and acral papulokeratotic lesions associated with myxoedema due to Hashimoto thyroiditis

A case is described of a patient with generalized myxoedema due to Hashimoto thyroiditis involving lesions of reticular erythematous mucinosis and acral papulokeratotic lesions with 'church spire' histological pattern. Substitutive treatment with thyroid hormone led to a rapid regression of the cutaneous lesions. The infrequent association of reticular erythematous mucinosis lesions and other forms of cutaneous mucinoses with hypothyroidism is discussed, with special emphasis on the fact that the underlying thyroid disease in all cases was Hashimoto thyroiditis. The association of distal keratotic papules with hypothyroidism has not been previously reported in the literature.

Data-intensive Undergraduate Research Project Informs to Advance Healthcare Analytics

The overarching framework for incorporating informatics into the Wesley College (Wesley) undergraduate curriculum was to teach emerging information technologies that prepared undergraduates for complex high-demand work environments. Federal and State support helped implement Wesley's undergraduate Informatics Certificate and Minor programs. Both programs require project-based coursework in Applied Statistics, SAS Programming, and Geo-spatial Analysis (ArcGIS). In 2015, the State of Obesity listed the obesity ranges for all 50 US States to be between 21-36%. Yet, the Center for Disease Control and Prevention (CDC) mortality records show significantly lower obesity-related death-rates for states with very high obesity-rates. This study highlights the disparities in the reported obesity-related death-rates (specified by an ICD-10 E66 diagnosis code) and the obesity-rate percentages recorded for all 50 US States. Using CDC mortality-rate data, the available obesity-rate information, and ArcGIS, we created choropleth maps for all US States. Visual and statistical analysis shows considerable disparities in the obesity-related death-rate record-keeping amongst the 50 US States. For example, in 2015, Vermont with the sixth lowest obesity-rate had the highest reported obesity-related death-rate. In contrast, Alabama had the fifth highest adult obesity-rate in the nation, yet, it had a very low age-adjusted mortality-rate. Such disparities make comparative analysis difficult.

A 2.4 GHz ULP OOK Single-Chip Transceiver for Healthcare Applications

This paper describes an ultra-low power (ULP) single chip transceiver for wireless body area network (WBAN) applications. It supports on-off keying (OOK) modulation, and it operates in the 2.36-2.4 GHz medical BAN and 2.4-2.485 GHz ISM bands. It is implemented in 90 nm CMOS technology. The direct modulated transmitter transmits OOK signal with 0 dBm peak power, and it consumes 2.59 mW with 50% OOK. The transmitter front-end supports up to 10 Mbps. The transmitter digital baseband enables digital pulse-shaping to improve spectrum efficiency. The super-regenerative receiver front-end supports up to 5 Mbps with -75 dBm sensitivity. Including the digital part, the receiver consumes 715 μW at 1 Mbps data rate, oversampled at 3 MHz. At the system level the transceiver achieves PER=10 (-2) at 25 meters line of site with 62.5 kbps data rate and 288 bits packet size. The transceiver is integrated in an electrocardiogram (ECG) necklace to monitor the heart's electrical property.

Quantitative Automated Segmentation of Lipiodol Deposits on Cone Beam CT Imaging acquired during Transarterial Chemoembolization for Liver Tumors: A Deep Learning Approach

PURPOSE

The purpose of this study was to show that a deep learning-based, automated model for Lipiodol segmentation on CBCT after cTACE performs closer to the "ground truth segmentation" than a conventional thresholding-based model.

MATERIALS & METHODS

This post-hoc analysis included 36 patients with a diagnosis of HCC or other solid liver tumor who underwent cTACE with an intra-procedural CBCT. Semi-automatic segmentation of Lipiodol were obtained. Then, a convolutional U-net model was used to output a binary mask that predicts Lipiodol deposition. A threshold value of signal intensity on CBCT was used to obtain a Lipiodol mask for comparison. Dice similarity coefficient (DSC), Mean-squared error (MSE), and Center of Mass (CM), and fractional volume ratios for both masks were obtained by comparing them to the ground truth (radiologist segmented Lipiodol deposits) to obtain accuracy metrics for the two masks. These results were used to compare the model vs. the threshold technique.

RESULTS

For all metrics, the U-net outperformed the threshold technique: DSC (0.65±0.17 vs. 0.45±0.22,p<0.001) and MSE (125.53±107.36 vs. 185.98±93.82,p=0.005). Difference between the CM predicted, and the actual CM was (15.31±14.63mm vs. 31.34±30.24mm,p<0.001), with lesser distance indicating higher accuracy. The fraction of volume present ([predicted Lipiodol volume]/[ground truth Lipiodol volume]) was 1.22±0.84vs.2.58±3.52,p=0.048 for our model's prediction and threshold technique, respectively.

CONCLUSION

This study showed that a deep learning framework could detect Lipiodol in CBCT imaging and was capable of outperforming the conventionally used thresholding technique over several metrics. Further optimization will allow for more accurate, quantitative predictions of Lipiodol depositions intra-procedurally.

Step by step optimization of a sperm cryopreservation protocol for spotted wolffish (Anarhichas minor Olafsen, 1772)

Spotted wolffish Anarhichas minor reproduction in captivity is dependent on in vitro fertilization. However, low sperm volume with relatively low cell concentration and the lack of gametes synchronization (simultaneous availability of mature eggs and sperm) represent a challenge for the industry. Thus, the development of protocols for sperm storage are crucial. Four sequential experiments were conducted to optimize a sperm cryopreservation protocol for this species. First, three different cryoprotectants (DMSO; 1, 2-propanediol; and methanol) at different concentrations (5, 10, and 20%) were tested for their toxicity. No significant differences (p > 0.05) were detected between the control samples and cryoprotectants at concentration up to 10% DMSO, 10% propanediol, and 20% methanol in terms of motility parameters. Second, using the highest non-toxic concentrations of cryoprotectants, sperm was cryopreserved in 0.5 mL straws, at different distances from the liquid nitrogen (1.5, 2.5, 4.5, and 7.5 cm) that correspond to different freezing rates. Motility parameters after freezing/thawing decreased for all the cryoprotectants (p < 0.001), however, methanol had the lowest protective capacity while DMSO the highest. Afterwards, two different thawing rates (1 min at 5 °C; and 25 s at 10 °C) were tested using only 10% DMSO and 10% propanediol. Both for the DMSO and propanediol, there were no significant differences (p > 0.05) between the two thawing rates. The best results were obtained using 10% DMSO. Finally, the fertilization capacity of cryopreserved sperm (10% DMSO and thawed at 5 °C for 1 min) was tested against fresh sperm using two spermatozoa:egg ratios and 4 h gametes contact time. The ratio of eggs with normal cell cleavage, abnormal cleavage or undeveloped were counted at the 2-4 cell stage. Cryopreserved sperm showed lower fertilization capacity at a concentration of 5 × 10⁴ spermatozoa:egg compared with fresh sperm (p < 0.001). At a concentration of 5 × 10⁵ spermatozoa:egg, similar fertilizations rates to the fresh sperm were obtained. The presence of the cryoprotectant DMSO during the 4 h contact time did not affect the fertilization rate or the percentage of embryos with abnormal cleavage (p > 0.05). To cryopreserve spotted wolffish sperm it is recommended to use 10% DMSO, loaded in 0.5 mL straws, freeze at a height between 4.5 (-14.05 °C/min) and 7.5 cm (-5.9 °C/min) from liquid nitrogen for 10 min and thaw for 1 min at 5 °C (177.9 °C/min). In vitro fertilization with cryopreserved sperm should be performed with a concentration of at least 5 × 10⁵ spermatozoa per egg.

Molecular MRI of T-cell immune response to cryoablation in immunologically hot vs. cold hepatocellular carcinoma

Background & Aims

Increasing enthusiasm around integrating locoregional therapy with systemic immunotherapy in primary liver cancer underscores the need for non-invasive imaging biomarkers. In this study, we aimed to establish advanced molecular MRI tools for monitoring T-cell responses to cryoablation in murine models, distinguishing between immunologically "hot" and "cold" hepatocellular carcinoma (HCC).

Methods

Immunocompetent 7-10-week-old C57BL/6J and BALB/cJ mice (n = 18 each) received carbon tetrachloride for 12 weeks to induce cirrhosis. Intrinsically immunogenic Hepa1-6 ("hot") and non-immunogenic TiB75 ("cold") cells were orthotopically implanted into C57BL/6 or BALB/c mice, respectively, to generate focal HCC lesions. After one week, animals were randomly assigned to (A) partial cryoablation (pCryo) (1.2 mm cryoprobe, -40 °C) or (B) no treatment (n = 8 per group and tumor type). Gadolinium 160 (160Gd)-labeled CD8+ antibody was administered intravenously either 1 week after tumor induction (control) or 1-week post (pCryo) (treatment). T1-weighted MRI scans were performed using a 9.4 T MRI scanner. Radiological-pathological correlation included imaging mass cytometry and immunohistochemistry.

Results

pCryo-treated Hepa1-6 tumors displayed peritumoral ring enhancement on T1-weighted MRI with 160Gd-CD8, correlating with imaging mass cytometry signal patterns. Untreated Hepa1-6 tumors lacked such enhancement. Radiological-pathological correlation confirmed significantly increased tumor-infiltrating CD8+ T lymphocytes in pCryo Hepa1-6 tumors compared with untreated tumors (p <0.001), and a stronger local response compared with systemic lymph nodes (p = 0.0415). Increased T-lymphocyte infiltration was not observed in TiB75 tumors, as indicated by MRI and histopathology.

Conclusion

pCryo induced increased T-cell infiltration in Hepa1-6 tumors compared to TiB75 tumors. T1-weighted MRI, following 160Gd-CD8 antibody administration, reproducibly detected the ablation-induced changes. These findings encourage further investigation of MRI-based molecular imaging biomarkers to assess immune responses to local tumor therapies.

Impact and implications

This study successfully established reliable MR-based molecular imaging tools to visualize CD8+ anti-tumor specific T-cell infiltration following partial cryoablation (pCryo) in murine tumor models. The study's significance lies in advancing our understanding of immune responses within induced cirrhosis and distinguishing between "hot" and "cold" tumor phenotypes. The findings not only build upon previous proof-of-principle data but also extend this technology to include different immune cell types in hepatocellular carcinoma. The study reveals that pCryo may exert specific effects on the tumor microenvironment, augmenting the anti-tumor immune response in immunogenic tumors while displaying a weaker local effect in non-immunogenic tumors.

Risk of post-intubation cardiac arrest with the use of high-dose rocuronium in COVID-19 patients with acute respiratory distress syndrome: A retrospective cohort study

BACKGROUND

Post-intubation cardiac arrest (PICA) is an uncommon complication of intubation, but numbers have risen to over 1.5 times the usual number since the coronavirus disease 2019 (COVID-19) pandemic. Due to expert recommendations, high-dose rocuronium (HDR) has become a commonly used pre-intubation neuromuscular blocking agent.

AIM

We conducted this retrospective case-control observational study with the hypothesis that high-dose rocuronium was not associated with higher incidence of PICA.

METHODS

We included 93 patients who were intubated using the rapid sequence intubation (RSI) technique with rocuronium for acute respiratory distress syndrome (ARDS) due to confirmed COVID-19 pneumonia, admitted from March 2020 to February 2021 to a tertiary care hospital in North Carolina, USA. The patients were grouped based on high (1.5 mg/kg of ideal body weight and above) versus low (<1.5 mg/kg of ideal body weight) dose rocuronium used for RSI. The differences of the various outcomes between the groups were analyzed.

RESULTS

The baseline demographics were similar in both groups except for higher body mass index in high-dose group 39 versus 32 (kg/m²), p = 0.009. There was a total of six PICA events (6.45%). The HDR group had 8.0% of PICA versus 4.7% in the low-dose group. In-hospital mortality was 60.0% in the HDR group versus 72.1% in the low-dose group.

CONCLUSION

The incidence of PICA in COVID-19 patients with ARDS who were intubated using the RSI technique was higher than in the pre-COVID-19 era.

RELEVANCE FOR PATIENTS

The use of high-dose paralytics during invasive ventilation with RSI and their consequences should be explored with the help of large-scale studies. The rate of PICA is still very low, and perhaps, the use of HDR is safe, as suggested by the expert panel.

Predicting tumor recurrence on baseline MR imaging in patients with early-stage hepatocellular carcinoma using deep machine learning

Tumor recurrence affects up to 70% of early-stage hepatocellular carcinoma (HCC) patients, depending on treatment option. Deep learning algorithms allow in-depth exploration of imaging data to discover imaging features that may be predictive of recurrence. This study explored the use of convolutional neural networks (CNN) to predict HCC recurrence in patients with early-stage HCC from pre-treatment magnetic resonance (MR) images. This retrospective study included 120 patients with early-stage HCC. Pre-treatment MR images were fed into a machine learning pipeline (VGG16 and XGBoost) to predict recurrence within six different time frames (range 1-6 years). Model performance was evaluated with the area under the receiver operating characteristic curves (AUC-ROC). After prediction, the model's clinical relevance was evaluated using Kaplan-Meier analysis with recurrence-free survival (RFS) as the endpoint. Of 120 patients, 44 had disease recurrence after therapy. Six different models performed with AUC values between 0.71 to 0.85. In Kaplan-Meier analysis, five of six models obtained statistical significance when predicting RFS (log-rank p < 0.05). Our proof-of-concept study indicates that deep learning algorithms can be utilized to predict early-stage HCC recurrence. Successful identification of high-risk recurrence candidates may help optimize follow-up imaging and improve long-term outcomes post-treatment.

Intracellular studies of the nucleoside reverse transcriptase inhibitor active metabolites: a review

Nucleoside reverse transcriptase inhibitors (NRTIs) plasma concentrations do not correlate with clinical efficacy or toxicity. These agents need to be phosphorylated to become active against HIV-infection. Thus, the characterization of the NRTIs intracellular metabolite pharmacological parameters will provide a better understanding that could lead to the development of more rational dose regimens in the HIV-infected population. Furthermore, intracellular measurements of NRTIs may provide a better marker with respect to clinical efficacy and toxicity than plasma concentrations. Thus, in this article we review the latest information regarding the intracellular pharmacological parameters of zidovudine (ZDV) and lamivudine (3TC) active metabolites in HIV-infected patients including the results from our recent clinical studies. We will start the discussion with ZDV and 3TC clinical efficacy, followed by systemic pharmacokinetics studies. We will then discuss the in vitro and in vivo intracellular studies with particular emphasis in the method development to measure these metabolites and we will conclude with the most current data from our clinical trials.

Women's Leadership Development at the Yale School of Medicine: Preliminary Evaluation of an Innovative Program

Background

Despite strong data indicating women leaders' proven efficacy as catalysts for organizational change, there is significant attrition for women across the advancement, promotion, and leadership pathways within academic medicine. To help early-career women faculty build a network of support, enhance leadership capacity and agility, and gain the skills necessary for career advancement and fulfillment, we created the Women's Leadership Development Program (WLDP) at our medical school in 2020.

Methods

From 2023 to 2024, we collected retrospective survey data from all interested prior participants to gauge the impact of the WLDP on faculty members' confidence, sense of belonging at Yale School of Medicine, and acquisition of leadership skills.

Results

Findings indicate the WLDP's positive impact on women faculty members' sense of leadership efficacy and skills, with participants reporting enhanced appreciation of their leadership potential, knowing how to lead with their strengths, improved leadership vision, and increased confidence in making an impact in academic medicine going forward.

Conclusion

The importance of leadership development programming for the professional development of early-career women faculty in academic medicine is explored. The article concludes with implications of these findings for our ongoing programming and leadership development initiatives for women in academic medicine more broadly.