Additional Clinical Tool Research Articles

Assessment of sperm chromosomal abnormalities using fluorescence in situ hybridization (FISH): implications for reproductive potential.

Chromosomal abnormalities play an important role in male infertility, which is becoming a significant issue in human fertility. Aim of this study was to evaluate the incidence of spermatic aneuploidies and diploidies in human sperm, according to semen parameters. We performed semen analysis according to the 6th edition of WHO criteria in 50 male subjects; samples weredivided into normozoospermic (n = 23) or thosewith altered seminal parameters (n = 27). To assess chromosomal numerical alterations of sperm, fluorescence in situ hybridization (FISH) was used. A significant increase in aneuploidies and diploidies was observed in samples with altered seminal parameters. Furthermore, stratifying this group, we observed a significant increase in aneuploidies and total abnormalities in oligozoospermic, asthenoteratozoospermic (AT), and oligoteratoasthenozoospermic (OAT) samples compared to normozoospermic. Our results showed the correlation between altered seminal parameters and numerical chromosomal abnormalities, confirming that sperm FISH analysis could be an additional clinical tool to assess reproductive potential in infertile males. Moreover, our results point to the importance of updating the normality ranges for detecting chromosomal aneuploidies using FISH.

#234 Clinical spectrum and genetic variants of Alport syndrome and thin basement membrane nephropathy—single center experience

Abstract Background and aims Alport syndrome (AS) and thin basement membrane nephropathy (TBMN) are genetically heterogeneous kidney diseases that manifest with kidney involvement, AS also with hearing and visual impairment. Electron microscopic examination shows characteristic ultrastructural changes in the glomerular basement membrane (GBM) in AS and TBMN, but cannot reliably distinguish between the two entities. Therefore, molecular genetic studies and the identification of individual pathogenic variants in the target genes are crucial to confirm the diagnosis. The aim of our study is to determine the significance of the genetic variants associated with the ultrastructural changes of GBM found in the renal biopsy. Method We retrospectively analyzed records of patients from the University Medical Centre Ljubljana in which ultrastructural GBM changes characteristic for AS and TBMN were found in the renal biopsy, including their clinical, laboratory and histological features. Molecular genetic investigations were made using the new generation sequencing method (NGS) to determine germline pathogenic variants in genes directly related to AS and TBMN (COL4A3, COL4A4 and COL4A5) and in genes that are important in syndromes with a related clinical picture (COL4A6, CD151, LMX1B, MYH9, FN1 and MYO1E). The pathogenicity of variants was determined according to the Clinical Molecular Genetic Society best practice guidelines. Results The study included 73 patients with ultrastructurally confirmed thin GBM. Indications for kidney biopsy were chronic nephritis syndrome in 33 patients (45%), acute worsening of renal function in 16 (22%), nephrotic syndrome in 9 (12%), nephrotic proteinuria and chronic kidney disease in 6 (8%), isolated proteinuria in 5 (7%) and suspected vasculitis in 4 patients (6%). At the time of kidney biopsy average age was 50 ± 16 years, average creatinine 112 ± 70 µmol/L and average estimated glomerular filtration rate (eGFR) 65 ± 24 ml/min/1.73 m2, 7 patients had eGFR below 30 ml/min/1.73 m2. Average daily proteinuria was 2.4 ± 3.3 gr and 88% of patients had hematuria. 38% of them have hearing impairment and 43% had positive familiar history of kidney disease. We recorded 33 patients (45%) with genetic variants associated with AS or TBMN: 22 patients (67%) with pathogenic variants, 2 patients (6%) with likely pathogenic and 9 patients (27%) with variants of uncertain significance. The presence of a positive genetic analysis was associated with a higher level of hematuria (p = 0.003), a lower level of proteinuria (p = 0.004) and a positive family history of kidney disease (p < 0.001). It was also associated with hearing loss, but the association was not statistically significant (p = 0.099). Patients with genetic variants had similar eGFR to those with negative genetics (63.9 ml/min/1.73 m2 (58.3-69.4) vs 66.2 ml/min/1.73 m2 (60.0-72.3)), p = 0.698. We also found no differences in GBM thickness in patients without compared to those with identified gene variants (213 nm (160-315) vs. 209 nm (140-410)), p = 0.761. 32 patients (44%) had only focal chronic changes and ultrastructural changes of thin GBM present on kidney biopsy and 41 patients (56%) had also been diagnosed with other renal pathology. When comparing these two groups, patients without associated pathology had lower daily proteinuria (p = 0.048), higher level of hematuria (p = 0.021), frequent hearing impairment (p = 0.008) and also positive genetics analysis (p = 0.016). Conclusion We have shown that in patients with proven ultrastructural alterations in GBM, the presence of so far recognized genetic variants associated with AS and TBMN is 45%, and corresponds to the frequency of other phenotypic characteristics of AS, including hearing impairment and positive family history. In the future, additional clinical tools will be required to accurately determine the role of coexistent thin GBM on the prognosis of patients with other relevant kidney pathology and other genetic tools beyond NGS should be employed to explore other pathologic genetic variants associated with the AS spectrum.

Hallux Valgus Plantar Pressure Distribution before and after a Distal Metatarsal Osteotomy.

Background: Hallux valgus (HV) morphological alterations impact forefoot kinetics. Surgery aims to restore both the morphology and function. Plantar pressure (PP) distribution systems represent an innovative additional tool to evaluate the hallux functional outcome after surgery in order to assess the hallux dorsiflexion, coupled with plantar flexion of the first ray. However, the literature reports limited evidence regarding the rebalancing of the plantar pressure distribution following surgery. The purpose of the present study was to examine the PP distribution in HV patients before and after a distal metatarsal osteotomy using a novel anatomically based protocol for in-shoe plantar load analysis during gait. Methods: A consecutive series of 18 patients with mild-to-moderate symptomatic HV who underwent a distal metatarsal osteotomy (S.E.R.I. technique) were prospectively evaluated using clinical scores (AOFAS and NRS), radiographic parameters (hallux valgus angle, intermetatarsal angle), and PP measurements via W-INSHOE© (Medicapteurs, Balma, France). Data were collected preoperatively and 12 months after surgery. Results: At 12 months follow-up, 3 patients were lost to follow-up, leaving 15 patients (24 HV) for examination. Both clinical and radiographical outcomes showed significant improvements from the pre- to postoperative periods. The PP distribution pattern revealed a significant increase in the peak pressure under the first metatarsal head associated with a significant increase in the peak pressure under the central metatarsals area between the pre- and postoperative periods. Conclusions: PP measurement systems hold promise as an additional clinical tool, yet current findings remain inconclusive. Further long-term follow-up studies that incorporate additional parameters are warranted.

Heterophoria in multiple sclerosis patients: a proof of principle cross-sectional study.

The pathophysiology of multiple sclerosis (MS) involves inflammatory neurodegeneration in the brainstem, cerebellum, and retina. The clinical relevance of oculomotor involvement in MS, however, remains uncertain. In this cross-sectional study, we evaluated heterophoria as a (sub)clinical tool in 54 MS patients and 55 age-matched healthy controls (HCs). We quantified heterophoria in prism diopters for distance and near range with orthoptic examination. Our primary outcome was high degrees of horizontal heterophoria (HDHH) defined as measurements beyond ±2 standard deviations from the mean prism diopter of heterophoria of our HCs. More than one-third (37%, n=20/54) of MS patients but only 11% (n=6/55) of HCs were classified as HDHH [distance, MS=9% (n=5/54) versus HC=6% (n=3/55); near, MS=19% (n=10/54) versus HC=5% (n=3/55)]. Our MS patients presented more combined vertical and horizontal deviations at near range [MS 19% (n=10/54) versus for HC 7% (n=4/55)]. We observed the combination of HDHH both at distance and at near testing in 9% (n=5/54) of MS patients but not at all in HCs (n=0/55). Despite the high prevalence of heterophoria, HDHH may be an additional (sub)clinical tool of subclinical involvement in MS. Thus, orthoptic examination may be an additional tool to improve MS diagnostic procedures.

Prediction of adverse clinical outcomes in pregnant women with severe and extremely severe forms of coronavirus infection

The objective was to identify prognostic criteria for unfavorable outcome in pregnant women with severe and extremely severe forms of COVID-19 and to build a model for predicting clinical outcome.Materials and methods. The cohort single-center retrospective study was conducted, which included 83 patients who were treated in the intensive care unit (ICU) from January 1 to December 31, 2021. Of these, 13 patients had an unfavorable outcome – death, and 70 patients with a successful outcome – recovery. The differences in the main clinical and laboratory parameters of patients of both groups during hospitalization in the ICU and on the 3rd day of treatment (Δ – delta) were analyzed.Results. The Cox regression analysis identified laboratory parameters, the difference of which (Δ) on admission to the ICU and on the 3rd day of treatment is associated with the development of the unfavorable outcome (death). These indicators were used as variables in a linear regression equation. The equation for calculating the prognostic index met the criteria of a statistically significant model (sensitivity 84.6 %, specificity 85.7 %, area under the operating characteristic curve (AUROC – Area Under Receiver Operator Curve) – 0.959 (95 % confidence interval [95 % CI] 0.918 – 1.0).Conclusion. The calculation of the prognostic index can be an additional clinical tool that allows one to predict the development of an unfavorable outcome, concentrate the work of a multidisciplinary team, attract additional reserves of a medical institution and/or evacuate such patients to high-level hospitals.

Pre-Treatment Trends in Child-Pugh Score as an Indicator of Post-Treatment Survival in Patients Receiving Liver SBRT for HCC

We sought to understand the value of Child-Pugh (CP) score trends prior to undergoing stereotactic body radiation therapy (SBRT) for hepatocellular carcinoma in patients with advanced cirrhosis, as an indicator of post-treatment morbidity and mortality. We hypothesize that an uptrend in CP score prior to RT increases risk of post-treatment cirrhosis progression, or death. We retrospectively reviewed all patients who underwent definitive SBRT for HCC between 2014-2022 in our health system. Most patients were referred for treatment in the 2nd or 3rd line setting, allowing us to determine CP score at multiple points before SBRT. Response to treatment was evaluated with RECIST or mRECIST criteria. Acute treatment toxicities were assessed by CTCAE v5. OS was assessed using the Kaplan-Meier method, and differences between groups were evaluated using log-rank test. A total of 61 patients were identified, 26 had an immediate pre-SBRT CP score of A5, 11 with A6, 10 with B7, 4 with B8, 4 with B9, 5 with C10, and 1 with C11. Median prescribed dose was 40Gy in 5fx. Median OS of all patients was 24 months. When stratified by CP category, median OS for CP A was not reached (NR) at time of analysis, CP B had a median OS of 14.8mo, and CP C with 1.9mo (p < 0.01). Local control rate at 6mo was 87.5%. 5 patients (8.3%) had CTCAE grade 2 acute toxicity. 10 patients had CP score progression of 2pts or more within 6mo after treatment, and 7 patients had a cause of death attributed to end stage liver disease. Median time interval between HCC diagnosis and start of RT was 338 days. In this time interval, patients with a CP score increase of 2 pts or more prior to starting RT had a median OS of 362 days, compared to NR for patients without increase (p = 0.02). When excluding the CP A group, patients with 2 pt increase had median OS of 362 days vs 445 days (p = 0.34). Again excluding the CP A group, patients with a 1 pt increase had median OS of 362 days vs NR (p = 0.23). Of 9 patients who had a pre-RT CP score increase of 2 pts or more, 7 experienced continued CP progression after treatment. In this multi-institutional retrospective analysis, we found 24 patients with advanced CP B/C cirrhosis who underwent SBRT, none of whom received orthotopic liver transplant. While CP C patients did relatively poorly, we find that some patients with CP B cirrhosis may tolerate SBRT well with good oncologic effect. When taking pre-treatment CP score increase into consideration, we saw a trend but no statistical significance indicating that a pre-SBRT increase in CP score may be associated with worse OS after treatment among CP B/C patients. We conclude that there may be a subset of patients with advanced cirrhosis who, if well selected, are appropriate candidates for SBRT. We suggest a novel use of the CP score and pre-RT trends as an additional clinical tool to aid in decision making when selecting patients. We also suggest that patients with marked up-trending scores pre-treatment have a high likelihood of continued cirrhosis progression after treatment.

Assessing cortical bone porosity with MRI in an animal model of chronic kidney disease

Chronic kidney disease (CKD) is characterized by secondary hyperparathyroidism and an increased risk of hip fractures predominantly related to cortical porosity. Unfortunately, bone mineral density measurements and high-resolution peripheral computed tomography (HR-pQCT) imaging have shortcomings that limit their utility in these patients. Ultrashort echo time magnetic resonance imaging (UTE-MRI) has the potential to overcome these limitations by providing an alternative assessment of cortical porosity. The goal of the current study was to determine if UTE-MRI could detect changes in porosity in an established rat model of CKD.Cy/+ rats (n = 11), an established animal model of CKD-MBD, and their normal littermates (n = 12) were imaged using microcomputed tomography (microCT) and UTE-MRI at 30 and 35 weeks of age (which approximates late-stage kidney disease in humans). Images were obtained at the distal tibia and the proximal femur. Cortical porosity was assessed using the percent porosity (Pore%) calculated from microCT imaging and the porosity index (PI) calculated from UTE-MRI. Correlations between Pore% and PI were also calculated.Cy/+ rats had higher Pore% than normal rats at both skeletal sites at 35 weeks (tibia = 7.13 % +/− 5.59 % vs. 0.51 % +/− 0.09 %, femur = 19.99 % +/− 7.72 % vs. 2.72 % +/− 0.32 %). They also had greater PI at the distal tibia at 30 weeks of age (0.47 +/− 0.06 vs. 0.40 +/− 0.08). However, Pore% and PI were only correlated in the proximal femur at 35 weeks of age (ρ = 0.929, Spearman).These microCT results are consistent with prior studies in this animal model utilizing microCT imaging. The UTE-MRI results were inconsistent, resulting in variable correlations with microCT imaging, which may be related to suboptimal bound and pore water discrimination at higher magnetic field strengths. Nevertheless, UTE-MRI may still provide an additional clinical tool to assess fracture risk without using ionizing radiation in CKD patients.

Chapter 6: Diagnostic Considerations regarding Coronal Caries.

This chapter considers the main principles guiding diagnosis of the disease dental caries in clinical practice by means of clinical examination and radiographs as adjunct method. Dental professionals have been trained to diagnose caries disease by assessing clinical symptoms and signs of caries lesions complemented by radiographic examination as an adjunct method. Clinical examination is the foundation of the diagnosis and should be performed after removal of dental biofilm of tooth surfaces, air-drying, and under good illumination. Clinical diagnostic methods categorize caries lesions according to their severity and in some methods according to their activity. Caries lesion activity has been determined by surface reflection and texture. The detection of thick or heavy biofilm on tooth surfaces is an additional diagnostic clinical tool to estimate caries lesion activity. Patients with no caries experience, that is, without clinical and/or radiographic signs of caries lesions in the dentition, are considered caries inactive. Other caries-inactive patients may present inactive caries lesions/restorations in their dentition. In contrast, patients are considered caries active when presenting any active caries lesion at clinical level and/or any progressing lesion as demonstrated by at least two bitewing radiographs taken at different points in time. The main concern about caries-active patients is that caries lesions are likely to progress unless effective measures are implemented to interfere with its progression. Prescribed according to individual needs, bitewing radiographs provide additional information for clinical examination in the detection of approximal enamel and outer third dentine lesions that can be inactivated by nonoperative treatment.

Test-retest reliability of the computerized rotational head impulse test in the pediatric population

&lt;p&gt;&lt;strong&gt;Background:&lt;/strong&gt; This study aimed to determine the test-retest reliability of the computerized rotational head impulse test (crHIT) as an additional clinical tool to assess horizontal semi-circular canal (HSCC) function in pediatric population.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods: &lt;/strong&gt;To determine the test re-test reliability of the crHIT, the study included 29 normally developing children with a mean age of 12.2 years±2.7 (range: 8-17 years) with no history of vestibular symptoms and disorders. Participants underwent two crHITs within one session and one crHIT in the following session. Each crHIT included one protocol using an earth fixed target. The test-retest reliability was determined using a quantitative research approach with a repeated measures design.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results: &lt;/strong&gt;Mean angular vestibulo-ocular reflex (aVOR) gain of 1.01 (session 1), 1.00 (session 2), and 1.01 (session 3) were obtained. Regression analysis revealed no significant difference for leftward rotations within-session (p=0.608) and between-session (p=0.318) for the differences measured. The same was seen for rightward rotations revealing no significant difference within-session (p=0.631) and between-session (p=0.523). &lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions: &lt;/strong&gt;The crHIT is a reliable clinical tool in assessing HSCC functioning in the pediatric population as it demonstrates good test-retest repeatability. The crHIT is a valuable complementary assessment to the video head impulse test (vHIT), since it is well tolerated by children, it is simple to administer and head velocities of &amp;gt;100°/sec are easily attainable. Extending the pediatric vestibular test battery with crHIT can be a valuable diagnostic tool without adding to the overall test time.&lt;/p&gt;&lt;p&gt;&lt;strong&gt; &lt;/strong&gt;&lt;/p&gt;

Predicting mortality in critically ill patients requiring renal replacement therapy for acute kidney injury in a retrospective single-center study of two cohorts

Half of the critically ill patients with renal replacement therapy (RRT) dependent acute kidney injury (AKI) die within one year despite RRT. General intensive care prediction models perform inadequately in AKI. Predictive models for mortality would be an invaluable complementary tool to aid clinical decision making. We aimed to develop and validate new prediction models for intensive care unit (ICU) and hospital mortality customized for patients with RRT dependent AKI in a retrospective single-center study. The models were first developed in a cohort of 471 critically ill patients with continuous RRT (CRRT) and then validated in a cohort of 193 critically ill patients with intermittent hemodialysis (IHD) as the primary modality for RRT. Forty-two risk factors for mortality were examined at ICU admission and CRRT initiation, respectively, in the first univariate models followed by multivariable model development. Receiver operating characteristics curve analyses were conducted to estimate the area under the curve (AUC), to measure discriminative capacity of the models for mortality. AUCs of the respective models ranged between 0.76 and 0.83 in the CRRT model development cohort, thereby showing acceptable to excellent predictive power for the mortality events (ICU mortality and hospital mortality). The models showed acceptable external validity in a validation cohort of IHD patients. In the IHD validation cohort the AUCs of the MALEDICT RRT initiation model were 0.74 and 0.77 for ICU and hospital mortality, respectively. The MALEDICT model shows promise for mortality prediction in critically ill patients with RRT dependent AKI. After further validation, the model might serve as an additional clinical tool for estimating individual mortality risk at the time of RRT initiation.

Urinary MicroRNA Sensing Using Electrochemical Biosensor to Evaluate Colorectal Cancer Progression.

Research in cancer diagnostics has recently established its footing and significance in the biosensor sphere, emphasizing the idea of a unique probe design used as a sensor and actuator, to identify the presence of protein, DNA, RNA, or miRNA. The fluorescein isothiocyanate (FITC) probe and biotinylated probe are designed for a two-pronged approach to the detection of the urinary miR-21 and miR-141, both of which have demonstrated significance in the development and progression of colorectal cancer, a leading cause of mortality and morbidity. The remainder of the apparatus is composed of a modified screen-printed carbon electrode (SPCE), to which the probes adhere, that transduces signals via the redox reaction between H2O2 and HRP, measured with chronoamperometry and cyclic voltammetry. The precise nature of our ultra-non-invasive biosensor makes for a highly sensitive and practical cancer detector, concluded by the significance when establishing disease presence (miR-21 p-value = 0.0176, miR-141 p-value = 0.0032), disease follow-up (miR-21 p-value = 0.00154, miR141 p-value < 0.0005), and even disease severity. This article hopes to emphasize the potential of an additional clinical tool for the management of colorectal cancer.

Visible Occlusal Plaque Index Predicting Caries Lesion Activity

This study was undertaken to appraise the predictive validity of the Visible Occlusal Plaque Index (VOPI) in assessing occlusal caries lesion activity in adolescents. A total of 618 adolescents aged 10 to 15 y were examined at the beginning of the trial and 511 (82.7%) at the 2-y follow-up. Adolescents and parents answered questionnaires about demographics, oral health behavior, and family sociodemographic variables. The VOPI has a 4-point ordinal scale ranging from no plaque to heavy plaque. Molar teeth were assigned to group VOPI 0–1 (no/thin plaque; n = 2,539) and group VOPI 2–3 (thick/heavy plaque; n = 843). At baseline examination, occlusal surfaces at risk of transition (n = 3,382) were either sound (55%), inactive noncavitated lesions (21%), inactive cavitated lesions (1%), active noncavitated lesions (15%), or active cavitated lesions (7%). The relative risk (RR) for caries lesion transition was estimated. Sound occlusal surfaces with no or thin plaque were significantly more likely to remain sound (RR = 1.3; 95% confidence interval [CI]: 1.1–1.4) than those harboring thick or heavy plaque. Inactive noncavitated occlusal lesions presenting no or thin plaque were significantly less likely to progress to active noncavitated lesions (RR = 0.1; CI: 0.0–0.8) than their counterparts with thick or heavy plaque. Active noncavitated lesions harboring thick and heavy plaque had a significantly lowest chance of becoming sound (RR = 0.7; CI: 0.5–0.9) and a highest risk of remaining active (RR = 1.5; CI: 1.1–1.9). Stepwise logistic regression analyses were run according to surface status at baseline and showed that none of the nonclinical predictors were significant for the outcome. The presence of thick and heavy plaque on occlusal surfaces was a predictor for caries lesion development, progression and activity (P < 0.0001). In conclusion, besides being an additional clinical tool for oral hygiene assessment, the VOPI is a predictor for development, progression, and activity of occlusal caries lesion. This is of particular interest for assessment of occlusal lesions undergoing health-promoting transitions.

Genotype-Guided Prescription of Azathioprine Reduces the Incidence of Adverse Drug Reactions in TPMT Intermediate Metabolizers to a Similar Incidence as Normal Metabolizers.

IntroductionThiopurine drugs are purine nucleoside analogues used for treatment of different immune-related conditions. To date, different studies highlighted the importance of thiopurine methyltransferase (TPMT) genotyping in patients who initiate treatment with thiopurines to make an adequate dose adjustment. We aimed to investigate the influence of TPMT phenotype, concomitant treatments, and demographic characteristics on the incidence of adverse reactions (ADRs) in patients who start treatment with azathioprine (AZA).MethodsThis was an observational and retrospective study. The study population comprised 109 patients who started treatment with AZA following routine TPMT genotyping before June 2019 and who were routinely followed up at Hospital Universitario de La Princesa. The incidence of ADRs and treatment duration were evaluated according to TPMT phenotype.ResultsForty-five men and 64 women were recruited, with a mean age of 67.6 ± 18.5. The medical specialty with the most requests was dermatology (45.9%) and the most frequent disease for which genotyping was requested was bullous pemphigoid (27.5%). All patients were normal metabolizers (NM), except for eight intermediate metabolizers (IM) (7.3%); no poor metabolizers (PM) were found. The initial azathioprine dose was subtherapeutic in both groups (103.2 ± 45.4 mg in NMs and 75 ± 32.3 mg in IMs), increasing during the first months of treatment, especially in NMs (120.3 ± 41.3 vs. 78.6 ± 30.4 mg in IMs, p = 0.011). Most patients (73.4%) received corticosteroids to keep the disease under control; and for 41.2% of NMs, physicians were able to reduce the dose at 6 months post treatment. No IMs completed 6 months of treatment. Hepatotoxicity, gastric intolerance, and blood disorders were the most common ADRs. The incidence of ADRs in the sample was 28.4% (n = 31) with a similar trend between IMs (37.5%) and NMs (27.8%). Patients undergoing concomitant treatment with allopurinol were associated with a higher incidence of ADRs (n = 4, 100% vs. n = 105, 20%; p = 0.002).ConclusionTPMT genotyping before AZA prescription reduces ADR incidence in IMs to a similar level as NMs in the Spanish population. However, it is important to note no IMs completed 6 months of treatment, suggesting that there may be some differences in drug tolerability according to phenotype. In addition, most NMs are treated with subtherapeutic doses, are poorly followed up, and thus suffer avoidable ADRs. Finally, concomitant therapies that inhibit the xanthine oxidase enzyme (XDH), such as allopurinol, predispose to ADRs. Therefore, pharmacogenetic testing should be integrated as an additional clinical tool, in such a way that each patient receives personalized, precision treatment, where all factors influencing drug response are considered.

TP53 Alterations Enrich in Ezb/C3-like Subclassified Relapsed or Refractory DLBCL and Are Susceptible to BRD4 Protac Inhibition

Introduction: New Diffuse Large B-cell (DLBCL) treatments remain a clinical need despite the success of rituximab combined with CHOP chemotherapy (RCHOP), which results in durable responses in 60-70% of patients. Those refractory to or who relapse following first-line therapy (rrDLBCL) have a very poor outcome, with only 20% surviving beyond 5 years, although CAR-T cell therapy is making a significant impact. Genomic insights can inform mechanism and treatment studies within this population, specifically the precision application of CAR-T. Rushton et. al. recently analyzed a large rrDLBCL patient cohort, noting significant rises in specific genes during the transition to advanced disease (MS4A1, TP53, NFKBIE, FOXO1, and CREBBP), building on the innovations of pre-treatment classifications. Addressing the heterogeneous activation of oncogenic pathways remains a challenge. Inhibitors targeting genes responsible for epigenetic regulation of rrDLBCL represent an attractive option, namely the transcriptional regulator BRD4, with PROTAC inhibition resulting in downregulation of several key DLBCL oncogenes. Herein, we report the first genomic subclassifications of rrDLBCL, the enrichment of TP53 alterations in the EZB-like subclassification, and data supporting the application of BRD4-targeting PROTAC therapies.Methods: Non-negative matrix factorization (NMF) was applied to a publicly available cohort of 127 RCHOP-treated rrDLBCL patients with matching sequencing data. Marker selection was applied to the 2 emergent groups to detect differential presence of DNA alterations. A Pearson similarity matrix was applied to the rrDLBCL cohort and 3 pretreatment cohorts to detect patterns of DNA alteration association and exclusion. Next, CRISPR-KO gene scores were integrated against gene expression fold change values before and after BRD4 PROTAC treatment. Lasty, 4 DLBCL cell lines were assayed against the BRD4 PROTAC ARV-825, Venetoclax, and inhibitors of epigenetic regulation.Results: NMF produced 2 clusters based on DNA alterations from the rrDLBCL cohort: RR1 and RR2. Significantly associated genes (FDR ≤ 0.05) included MYD88, PIM1, IGLL5, HIST1HC, SOCS1, HIST1H1E, and CD79B in RR1 , and CREBBP, EZH2, STAT6, BCL2, TP53, TNFRSF14, CARD11, and double hit translocations in RR2. Notably, TP53 alterations significantly enriched in the EZB subclassification during rrDLBCL transition in comparison to pre-treatment distribution (P = 0.0016). Significant associations between TP53 and EZB genes were observed alongside significant exclusion from MCD and BN2-associated genes. Integrating significant gene expression changes following BRD4-PROTAC treatment and CRISPR-KO scores revealed the loss of several key oncogenes in cell lines, including BCL2, BCL6, CD79B, POU2F2, and MDM4. Markedly, reductions in 9 established GCB and 4 ABC gene signatures were observed alongside the reduction of the Reactome signature of TP53 Regulators of Expression and Degradation (FDR = 0.0377). In vitro inhibition assays measuring ARV-825 (BRD4 PROTAC) response revealed significantly lower rates of cell viability compared to Venetoclax across 4 cell lines.Conclusions: Our results indicate that distinct genomic groups exist within rrDLBCL, that TP53 alterations strongly associate with the EZB-enriched group, and that if TP53 alterations continue to predict poor CAR-T response, these tumors may be susceptible to BRD4 inhibition. Our observations indicate a significant climb in TP53 association with EZB tumors and their matched alterations after rrDLBCL transition in comparison to the pre-treatment landscape. Enrichment may indicate that EZB-like tumors lack some of the tools necessary to make the transition to advanced disease but provide an ideal environment for the acquisition of TP53 alterations. In contrast, the disassociation between TP53 alterations and MCD/BN2-like alterations may indicate that these tumors have more inherent capability to reject therapy. The emergence of BRD4-targeting PROTACs provides an additional clinical tool, one perhaps more suitable than Venetoclax against specific rrDLBCL cases. In closing, This study provides insights towards the rrDLBCL landscape and reinforces the necessity of evaluating tissue biopsies for TP53 alterations throughout treatment to guide precision application of therapy, noting susceptible pathways of these particular tumors. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Estimated pulse wave velocity improves risk stratification for all-cause mortality in patients with COVID-19

Accurate risk stratification in COVID-19 patients consists a major clinical need to guide therapeutic strategies. We sought to evaluate the prognostic role of estimated pulse wave velocity (ePWV), a marker of arterial stiffness which reflects overall arterial integrity and aging, in risk stratification of hospitalized patients with COVID-19. This retrospective, longitudinal cohort study, analyzed a total population of 1671 subjects consisting of 737 hospitalized COVID-19 patients consecutively recruited from two tertiary centers (Newcastle cohort: n = 471 and Pisa cohort: n = 266) and a non-COVID control cohort (n = 934). Arterial stiffness was calculated using validated formulae for ePWV. ePWV progressively increased across the control group, COVID-19 survivors and deceased patients (adjusted mean increase per group 1.89 m/s, P < 0.001). Using a machine learning approach, ePWV provided incremental prognostic value and improved reclassification for mortality over the core model including age, sex and comorbidities [AUC (core model + ePWV vs. core model) = 0.864 vs. 0.755]. ePWV provided similar prognostic value when pulse pressure or hs-Troponin were added to the core model or over its components including age and mean blood pressure (p < 0.05 for all). The optimal prognostic ePWV value was 13.0 m/s. ePWV conferred additive discrimination (AUC: 0.817 versus 0.779, P < 0.001) and reclassification value (NRI = 0.381, P < 0.001) over the 4C Mortality score, a validated score for predicting mortality in COVID-19 and the Charlson comorbidity index. We suggest that calculation of ePWV, a readily applicable estimation of arterial stiffness, may serve as an additional clinical tool to refine risk stratification of hospitalized patients with COVID-19 beyond established risk factors and scores.

Predicting length of stay after shoulder arthroplasty

Background/HypothesisThe annual volume of shoulder arthroplasty (SA) in the United States has increased more than 400% from 1993 to 2008 and is projected to increase an additional 300% from 2008 to 2030. The purpose of this study was to develop and internally validate a preoperative predictive nomogram for length of stay (LOS) after SA. We hypothesized that patient-specific covariates are responsible for increased LOS after SA. If sufficiently accurate, such a nomogram would be valuable for defining which patients would qualify for outpatient SA. MethodsA systematic review of the literature was performed to identify patient variables responsible for increased LOS defined as ≥ 2 days. Patient data were collected from 234 consecutive SA cases performed between 2010 and 2016 at a single tertiary healthcare center by six orthopedic surgeons. The cohort was separated into two groups: short LOS (≤1 day; n = 98) and extended LOS (≥2 days; n = 136). Logistic regression coefficients were used to construct an LOS nomogram that was internally validated by the bootstrapping method. A receiver operating characteristic curve plot determined the discriminative ability of the nomogram. Generalizability was assessed using external validation with a new data set of 193 records prospectively collected from 2016 to 2018. ResultsUnivariate analysis demonstrated that female sex, cancer history, anticoagulation and oral hypoglycemic agents, undergoing humeral head replacement for fracture, and discharge to a facility were significant predictors for an LOS ≥2 days. The following patient covariates were found to be significant in the development of the nomogram: age, female sex, procedure type, disease-modifying antirheumatic drugs (DMARDs), renal dysfunction, and diabetes drugs. The prediction accuracy of this model was good (area under the curve of the receiver operating characteristic curve plot of 0.793). External validation of the model reported an area under the curve of 0.664. ConclusionPatients most suitable for expedited postoperative stay are healthy middle-aged males that are not on diabetic medications or DMARDs, have no renal disease, and undergo resurfacing, total SA, or reverse total SA. This nomogram may be an additional clinical decision-making tool for effectively preparing for postoperative care and decreasing LOS for an episode of care, subsequently reducing the total cost of care. Future work would focus on undertaking a prospective multicenter study involving institutions that perform a high annual volume of SAs. Level of evidenceLevel III; Retrospective Cohort Study

Primary central nervous system lymphoma: advances in MRI and PET imaging.

Contrast enhanced magnetic resonance imaging (CE-MRI) remains the imaging modality of choice for initial workup, staging, and response assessment after therapy in patients with primary central nervous system lymphoma (PCNSL). While CE-MRI is a sensitive test to detect blood brain barrier (BBB) dysfunction, it does not biologically represent the true tumor burden. Current response assessment criteria relies heavily on two dimensional anatomical measurements on post contrast T1-weighted (T1W) images, as well as pre-contrast T2-weighted (T2W) imaging. Additional MRI features, such as diffusion-weighted imaging (DWI) and perfusion weighted imaging, can be routinely obtained at most centers with MRI capabilities. Emerging evidence supports the incorporation of these data to better define tumor physiology and provide additional valuable clinical tools capable of identifying high risk subgroups as well as early predictors of response to therapies. Further, novel advanced molecular and pathophysiologic characterization of PCNSL provides insights into promising targeted therapeutic approaches. However, significant institutional imaging variation and inconsistent clinical trial reporting diminishes the reliability, reproducibility and eventual translation in day to day management of patients with PCNSL. Here we review established neuroimaging concepts and provide an overview of published literature about novel imaging techniques that may improve diagnosis and response assessments. Finally, we highlight the need for standardization of image acquisition, post-processing, and incorporation of novel imaging biomarkers in early phase PCNSL clinical trials.

Association of bioavailable inhibin B and oocyte yield in controlled ovarian stimulation

ObjectiveTo determine if the biologically active or bioavailable inhibin B (bio-inhB) correlated with the oocyte yield in controlled ovarian stimulation (COS).DesignCross-sectional study.SettingAcademic center.Patient(s)Women undergoing oocyte cryopreservation.Intervention(s)None.Main Outcome Measure(s)Serum of women were sampled to measure bio-inhB at three points: baseline (“start”); middle (“mid”); and end of COS. A validated, highly specific enzyme-linked immunosorbent assay (Ansh Labs, Webster, TX) measured bio-inhB. The Spearman tests analyzed correlations between bio-inhB and other ovarian reserve markers, including age, follicle-stimulating hormone (FSH), antral follicle count (AFC), and antimüllerian hormone (AMH), and correlations between these markers and oocyte yield.Result(s)A total of 144 women were included. Bioavailable inhibin B at the mid and end of COS, plus its delta, were strongly correlated with other ovarian reserve markers. As the bio-inhB concentration increased, the AFC and AMH levels also increased, whereas the FSH concentration and age decreased. Bioavailable inhibin B values, except at the start of COS, were more strongly correlated with oocyte yield than the FSH concentration (r = 0.72–0.82 vs. r = −0.44) and correlated similarly to the AFC and AMH concentration (r = 0.79 and 0.81, respectively). These correlations strengthened in those with diminished ovarian reserve, specifically age ≥35 years or AMH concentration <2 ng/mL (r = 0.71–0.86 vs. r = 0.49–0.67).Conclusion(s)Predicting COS outcome is imperfect. When using a highly specific enzyme-linked immunosorbent assay, bio-inhB correlated with the oocyte yield similar to or more strongly than traditionally used ovarian reserve markers. These correlations strengthened in cases of diminished ovarian reserve. Bioavailable inhibin B provides physicians with an additional clinical tool for estimating COS outcome.

Perspectives of X-nuclei magnetic resonance imaging in neuro-oncology

X‑nuclei magnetic resonance imaging (MRI) yields abroad spectrum of metabolic and functional imaging techniques with increasing clinical feasibility. Current X‑nuclei techniques in (neuro)oncology with emphasis on potential clinical applications of sodium and oxygen MRI are described and discussed. Review with discussion of state-of-the-art literature on X‑nuclei imaging. X‑nuclei MRI employs NMR-sensitive nonproton nuclei to enable both anatomical visualization as well as noninvasive imaging and quantification of physiological processes in the human body. At the moment, sodium MRI represents the most common application of X‑nuclei MRI because of its comparatively high NMR signal. Moreover, its sensitivity to pathological cellular proliferation renders sodium MRI agood candidate for oncological imaging, yielding additional biochemical information to proton MRI. Oxygen MRI is currently primarily investigational, requiring high technical efforts and costs. However, preliminary results show ahuge potential of this technique for metabolic characterization of tumors. X‑nuclei MRI is arapidly evolving field in metabolic and functional imaging. In coming years, sodium MRI is expected to be increasingly used as an additional clinical tool in oncology to enhance diagnostic accuracy.

REM sleep atonia loss distinguishes synucleinopathy in older adults with cognitive impairment.

To determine whether quantitative polysomnographic REM sleep without atonia (RSWA) distinguishes between cognitive impairment phenotypes. Neurodegenerative cognitive impairment in older adults predominantly correlates with tauopathy or synucleinopathy. Accurate antemortem phenotypic diagnosis has important prognostic and treatment implications; additional clinical tools might distinguish between dementia syndromes. We quantitatively analyzed RSWA in 61 older adults who underwent polysomnography including 46 with cognitive impairment (20 probable synucleinopathy), 26 probable non-synucleinopathy (15 probable Alzheimer disease, 11 frontotemporal lobar dementia), and 15 age- and sex-matched controls. Submentalis and anterior tibialis RSWA metrics and automated REM atonia index were calculated. Group statistical comparisons and regression were performed, and receiver operating characteristic curves determined diagnostic RSWA thresholds that best distinguished synucleinopathy phenotype. Submentalis-but not anterior tibialis RSWA-was greater in synucleinopathy than nonsynucleinopathy; several RSWA diagnostic thresholds distinguished synucleinopathy with excellent specificity including submentalis tonic, 5.6% (area under the curve [AUC] 0.791); submentalis any, 15.0% (AUC 0.871); submentalis phasic, 10.8% (AUC 0.863); and anterior tibialis phasic, 31.4% (AUC 0.694). In the subset of patients without dream enactment behaviors, submentalis RSWA was also greater in patients with synucleinopathy than in those without synucleinopathy. RSWA was detected more frequently by quantitative than qualitative methods (p = 0.0001). Elevated submentalis RSWA distinguishes probable synucleinopathy from probable nonsynucleinopathy in cognitively impaired older adults, even in the absence of clinical dream enactment symptoms. This study provides Class III evidence that quantitative RSWA analysis is useful for distinguishing cognitive impairment phenotypes. Further studies with pathologic confirmation of dementia diagnoses are needed to confirm the diagnostic utility of RSWA in dementia.