External validation of the LENT and PROMISE prognostic scores for malignant pleural effusion

BackgroundAccurate survival estimation in malignant pleural effusion is essential to guide clinical management strategies and inform patient discussion. The LENT and PROMISE scores were developed to aid prognostication in malignant pleural effusion; however their uptake in practice has been limited. We aimed to conduct a detailed external validation of the LENT and PROMISE scores to develop recommendations regarding clinical utility, and to highlight factors limiting performance.MethodsMedical records of patients diagnosed with malignant pleural effusion between 2015-2023 at Oxford University Hospitals were retrospectively reviewed to determine length of survival and the LENT and PROMISE scores at diagnosis. Performance of the scores in predicting overall survival and chance of survival at 3, 6 and 12 months was assessed using measures of discrimination, calibration and overall model performance. Kaplan-Meier analysis and Cox models were utilised to further investigate individual score variables.Results773 patients with malignant pleural effusion were included. Both scores showed predictive ability for overall survival; however median survival estimates lacked precision. Score performance in predicting survival at 3, 6 and 12 months was stronger, with C-indices around 0.8 for both at each time point, and the models appearing well calibrated. Limited stratification of tumour types and lack of consideration of sensitising mutations were demonstrated to be potential factors restricting performance.ConclusionsBoth scores have the ability to prognosticate in malignant pleural effusion, and greater use in practice should be considered. However, areas to improve score performance were also highlighted, and these may aid future model development

External validation of the LENT and PROMISE prognostic scores for malignant pleural effusion

Background: Accurate survival estimation in malignant pleural effusion is essential to guide clinical management strategies and inform patient discussion. The LENT and PROMISE scores were developed to aid prognostication in malignant pleural effusion, however their uptake in practice has been limited. We aimed to conduct a detailed external validation of the LENT and PROMISE scores to develop recommendations regarding clinical utility, and to highlight factors limiting performance. / Methods: Medical records of patients diagnosed with malignant pleural effusion between 2015–2023 at Oxford University Hospitals were retrospectively reviewed to determine length of survival and the LENT and PROMISE scores at diagnosis. Performance of the scores in predicting overall survival and chance of survival at 3-, 6- and 12-months was assessed using measures of discrimination, calibration and overall model performance. Kaplan-Meier analysis and Cox models were utilised to further investigate individual score variables. / Results: 773 patients with malignant pleural effusion were included. Both scores showed predictive ability for overall survival, however median survival estimates lacked precision. Score performance in predicting survival at 3-, 6- and 12-months was stronger, with C-indices around 0.8 for both at each time-point, and the models appearing well-calibrated. Limited stratification of tumour types and lack of consideration of sensitising mutations were demonstrated to be potential factors restricting performance. / Conclusions: Both scores have ability to prognosticate in malignant pleural effusion, and greater use in practice should be considered. However, areas to improve score performance were also highlighted, and these may aid future model development

Changes to care delivery at nine international pediatric diabetes clinics in response to the COVID‐19 global pandemic

BACKGROUND: Pediatric diabetes clinics around the world rapidly adapted care in response to COVID-19. We explored provider perceptions of care delivery adaptations and challenges for providers and patients across nine international pediatric diabetes clinics. METHODS: Providers in a quality improvement collaborative completed a questionnaire about clinic adaptations, including roles, care delivery methods, and provider and patient concerns and challenges. We employed a rapid analysis to identify main themes. RESULTS: Providers described adaptations within multiple domains of care delivery, including provider roles and workload, clinical encounter and team meeting format, care delivery platforms, self-management technology education, and patient-provider data sharing. Providers reported concerns about potential negative impacts on patients from COVID-19 and the clinical adaptations it required, including fears related to telemedicine efficacy, blood glucose and insulin pump/pen data sharing, and delayed care-seeking. Particular concern was expressed about already vulnerable patients. Simultaneously, providers reported 'silver linings' of adaptations that they perceived as having potential to inform care and self-management recommendations going forward, including time-saving clinic processes, telemedicine, lifestyle changes compelled by COVID-19, and improvements to family and clinic staff literacy around data sharing. CONCLUSIONS: Providers across diverse clinical settings reported care delivery adaptations in response to COVID-19-particularly telemedicine processes-created challenges and opportunities to improve care quality and patient health. To develop quality care during COVID-19, providers emphasized the importance of generating evidence about which in-person or telemedicine processes were most beneficial for specific care scenarios, and incorporating the unique care needs of the most vulnerable patients

Synthesis, structure and luminescence properties of zinc and cadmium linear-chain compounds with anionic monoalkoxy-tetracyanopropenes bridged by 4,4 '-bipyridines

The synthesis, characterization and 3D structure determination of Zinc and Cadmium compounds are reported, containing the non-chelating bidentate ligand 4,4'-bipyridine and the anions 1,1,3,3-tetracyano-2-propoxy-propenide (tcnopr) or 1,1,3,3-tetracyano-2-ethoxy-propenide (tcnoet). The structures consist of linear chains (1D) built from metal ions and 4,4'-bipyridine, where the octahedral coordination around the metals is completed by two trans anions tcnoet (or tcnopr), and two trans-oriented water molecules. Weak interchain interactions are present, based on hydrogen bonds between the water ligands (both hydrogens are involved) and two CN groups of two nearby other chains. Metal-ligand distances appear as uneventful. For the same anion, the Zn and Cd compounds are isomorphous. Possible decomposition of the compounds has been investigated in the temperature range 30-800 degrees C in a static air atmosphere. Thermal analysis studies (TG, DTG, DTA) show that the axial water ligands for all three compounds are gradually lost upon heating above 60 degrees C to about 170 degrees C. Luminescence properties, recorded as powders, are reported as well, and these appear as strong for the Cd compound I, when irradiated at 390 nm, extremely weak for the Cd compound II, when irradiated at wavelengths from 300-400 nm, and moderately weak for the Zn compound III when irradiated at 385 nm. (C) 2019 The Author(s). Published by Elsevier Ltd.Metals in Catalysis, Biomimetics & Inorganic Material

Consensus guidance for monitoring individuals with islet autoantibody-positive pre-stage 3 type 1 diabetes

Given the proven benefits of screening to reduce diabetic ketoacidosis (DKA) likelihood at the time of stage 3 type 1 diabetes diagnosis, and emerging availability of therapy to delay disease progression, type 1 diabetes screening programmes are being increasingly emphasised. Once broadly implemented, screening initiatives will identify significant numbers of islet autoantibody-positive (IAb+) children and adults who are at risk of (confirmed single IAb+) or living with (multiple IAb+) early-stage (stage 1 and stage 2) type 1 diabetes. These individuals will need monitoring for disease progression; much of this care will happen in non-specialised settings. To inform this monitoring, JDRF in conjunction with international experts and societies developed consensus guidance. Broad advice from this guidance includes the following: (1) partnerships should be fostered between endocrinologists and primary-care providers to care for people who are IAb+; (2) when people who are IAb+ are initially identified there is a need for confirmation using a second sample; (3) single IAb+ individuals are at lower risk of progression than multiple IAb+ individuals; (4) individuals with early-stage type 1 diabetes should have periodic medical monitoring, including regular assessments of glucose levels, regular education about symptoms of diabetes and DKA, and psychosocial support; (5) interested people with stage 2 type 1 diabetes should be offered trial participation or approved therapies; and (6) all health professionals involved in monitoring and care of individuals with type 1 diabetes have a responsibility to provide education. The guidance also emphasises significant unmet needs for further research on early-stage type 1 diabetes to increase the rigour of future recommendations and inform clinical care. Graphical Abstract

Associations of disordered eating with the intestinal microbiota and short-chain fatty acids among young adults with type 1 diabetes

Background and aims: Disordered eating (DE) in type 1 diabetes (T1D) includes insulin restriction for weight loss with serious complications. Gut microbiota-derived short chain fatty acids (SCFA) may benefit host metabolism but are reduced in T1D. We evaluated the hypothesis that DE and insulin restriction were associated with reduced SCFA-producing gut microbes, SCFA, and intestinal microbial diversity in adults with T1D. Methods and results: We collected stool samples at four timepoints in a hypothesis-generating gut microbiome pilot study ancillary to a weight management pilot in young adults with T1D. 16S ribosomal RNA gene sequencing measured the normalized abundance of SCFA-producing intestinal microbes. Gas-chromatography mass-spectrometry measured SCFA (total, acetate, butyrate, and propionate). The Diabetes Eating Problem Survey—Revised (DEPS-R) assessed DE and insulin restriction. Covariate-adjusted and Bonferroni-corrected generalized estimating equations modeled the associations. COVID-19 interrupted data collection, so models were repeated restricted to pre-COVID-19 data. Data were available for 45 participants at 109 visits, which included 42 participants at 65 visits pre-COVID-19. Participants reported restricting insulin “At least sometimes” at 53.3% of visits. Pre-COVID-19, each 5-point DEPS-R increase was associated with a −0.34 (95% CI -0.56, −0.13, p = 0.07) lower normalized abundance of genus Anaerostipes; and the normalized abundance of Lachnospira genus was −0.94 (95% CI -1.5, −0.42), p = 0.02 lower when insulin restriction was reported “At least sometimes” compared to “Rarely or Never”. Conclusion: DE and insulin restriction were associated with a reduced abundance of SCFA-producing gut microbes pre-COVID-19. Additional studies are needed to confirm these associations to inform microbiota-based therapies in T1D

DNA methylation patterns identify subgroups of pancreatic neuroendocrine tumors with clinical association

Here we report the DNA methylation profile of 84 sporadic pancreatic neuroendocrine tumors (PanNETs) with associated clinical and genomic information. We identified three subgroups of PanNETs, termed T1, T2 and T3, with distinct patterns of methylation. The T1 subgroup was enriched for functional tumors and ATRX, DAXX and MEN1 wild-type genotypes. The T2 subgroup contained tumors with mutations in ATRX, DAXX and MEN1 and recurrent patterns of chromosomal losses in half of the genome with no association between regions with recurrent loss and methylation levels. T2 tumors were larger and had lower methylation in the MGMT gene body, which showed positive correlation with gene expression. The T3 subgroup harboured mutations in MEN1 with recurrent loss of chromosome 11, was enriched for grade G1 tumors and showed histological parameters associated with better prognosis. Our results suggest a role for methylation in both driving tumorigenesis and potentially stratifying prognosis in PanNETs

ROR1 and ROR2 expression in pancreatic cancer

Background: The Wnt receptors ROR1 and ROR2 are generating increased interest as cancer therapeutic targets but remain understudied in pancreatic ductal adenocarcinoma (PDAC). Compared to canonical Wnt/ β-catenin signalling, the role of noncanonical Wnt signalling in PDAC remains largely unknown. Only one study has investigated the prognostic significance of the noncanonical Wnt signalling receptor, ROR2 in PDAC. No studies have investigated the prognostic role of ROR1 in PDAC. Methods: Here, we performed analysis of ROR1 and ROR2 mRNA expression in three publicly available datasets ICGC-PACA-AU (n = 81), TCGA-PAAD (n = 150) and CPTAC-PDAC (n = 137). ROR1 and ROR2 protein expression from the CPTAC-PDAC discovery cohort were also analysed. Immunohistochemistry (IHC) using the validated anti ROR1 monoclonal antibody (4A5) was performed on the Australian Pancreatic Cancer Genome Initiative (APGI) cohort of PDAC samples (n = 152). Association between ROR1 cytoplasmic staining intensity and clinicopathological parameters including stage, grade and overall survival (OS) was investigated. Results: High ROR1 mRNA expression levels correlated with a favourable OS outcome in all of the ICGC-PACA-AU, TCGA-PAAD and CPTAC-PDAC cohorts. ROR1 protein expression was not associated with stage, grade or OS in the APGI cohort. Conclusion: ROR1 and ROR2 have potential as prognostic markers when measured at the mRNA level in PDAC. Our IHC cohort did not support ROR1 protein expression in predicting OS, and highlighted the discrepancy of prognostic biomarkers when measured by MS, IHC and RNAseq

Validating the predictive ability of the 2MACE score for major adverse cardiovascular events in patients with atrial fibrillation: results from phase II/III of the GLORIA-AF registry

The 2MACE score was specifically developed as a risk-stratification tool in atrial fibrillation (AF) to predict cardiovascular outcomes. We evaluated the predictive ability of the 2MACE score in the GLORIA-AF registry. All eligible patients from phase II/III of the prospective global GLORIA-AF registry were included. Major adverse cardiac events (MACEs) were defined as the composite outcome of stroke, myocardial infarction and cardiovascular death. Cox proportional hazards were used to examine the relationship between the 2MACE score and study outcomes. Predictive capability of the 2MACE score was investigated using receiver-operating characteristic curves. A total of 25,696 patients were included (mean age 71 years, female 44.9%). Over 3 years, 1583 MACEs were recorded. Patients who had MACE were older, with more cardiovascular risk factors and were less likely to be managed using a rhythm-control strategy. The median 2MACE score in the MACE and non-MACE groups were 2 (IQR 1-3) and 1 (IQR 0-2), respectively (p < 0.001). The 2MACE score was positively associated with an increase in the risk of MACE, with a score of & GE; 2 providing the best combination of sensitivity (69.6%) and specificity (51.6%), HR 2.47 (95% CI, 2.21-2.77). The 2MACE score had modest predictive performance for MACE in patients with AF (AUC 0.655 (95% CI, 0.641-0.669)). Our analysis in this prospective global registry demonstrates that the 2MACE score can adequately predict the risk of MACE (defined as myocardial infarction, CV death and stroke) in patients with AF. Clinical trial registration:. Unique identifiers: NCT01468701, NCT01671007 and NCT0193737

Lost in translation: Returning germline genetic results in genome-scale cancer research

Background: The return of research results (RoR) remains a complex and well-debated issue. Despite the debate, actual data related to the experience of giving individual results back, and the impact these results may have on clinical care and health outcomes, is sorely lacking. Through the work of the Australian Pancreatic Cancer Genome Initiative (APGI) we: (1) delineate the pathway back to the patient where actionable research data were identified; and (2) report the clinical utilisation of individual results returned. Using this experience, we discuss barriers and opportunities associated with a comprehensive process of RoR in large-scale genomic research that may be useful for others developing their own policies. Methods: We performed whole-genome (n = 184) and exome (n = 208) sequencing of matched tumour-normal DNA pairs from 392 patients with sporadic pancreatic cancer (PC) as part of the APGI. We identified pathogenic germline mutations in candidate genes (n = 130) with established predisposition to PC or medium-high penetrance genes with well-defined cancer associated syndromes or phenotypes. Variants from candidate genes were annotated and classified according to international guidelines. Variants were considered actionable if clinical utility was established, with regard to prevention, diagnosis, prognostication and/or therapy. Results: A total of 48,904 germline variants were identified, with 2356 unique variants undergoing annotation and in silico classification. Twenty cases were deemed actionable and were returned via previously described RoR framework, representing an actionable finding rate of 5.1%. Overall, 1.78% of our cohort experienced clinical benefit from RoR. Conclusion: Returning research results within the context of large-scale genomics research is a labour-intensive, highly variable, complex operation. Results that warrant action are not infrequent, but the prevalence of those who experience a clinical difference as a result of returning individual results is currently low