Citations

Abstract Rationale : Airway remodeling in asthma involves increased airway smooth muscle (ASM) mass, changes to bronchial epithelial cell (BEC) layer, and increased fibrosis. ASM and BECs actively contribute by secreting growth factors and cytokines, regulating extracellular matrix (ECM) composition and enhancing cell proliferation/migration. Altering mechanisms which modulate remodeling presents a key to novel therapeutic strategies. BDNF increases ASM [Ca2+]i and contractility, and potentiates the effects of inflammation. Importantly, studies show that ASM is not only a target, but also a source of BDNF, raising the possibility of local autocrine/paracrine effects. Arginase 1 and 2 are expressed by BECs, but their roles in asthma are still under investigation with studies showing arginase 1 inhibition blunting epithelial remodeling and ASM hyperplasia. Knockdown of appealing targets such as ASM BDNF and epithelial arginases using small interfering RNA (siRNA) is a promising approach to combating inflammatory lung remodeling. Polymer based nanoparticles have been constructed which demonstrate cell-type specificity and high efficiency in delivering siRNA. Thus, we hypothesize that BDNF and arginases are central to airway remodeling and can be targeted via nanopartiacles.Methods: Primary human ASM and BEC cells from non-asthmatic vs. asthmatic individuals were obtained post-surgery from lung tissues after approval Mayo Clinic IRB. PONI-Guan NP were generated using block copolymer engineering. PCR, immunoblotting and ELISA were performed using standard techniques. Contractility studies were conducted in adult mouse precision cut lung slices. In vivo lung function studies were conducted in 6-8 week old mice, with or without mixed allergen (MA) treatment and Scireq Flexivent system. Results: PONI-Guan NP uptake demonstrates cell-type specificity in BEC/ASM co-culture and mouse lung. Arginase I/II and ECM expression is upregulated in BECs when exposed to BDNF and cytokines. In ASM, BDNF is increased in asthmatics compared to non-asthmatic controls; ECM expression is increased in response to BDNF and TNF-α. In BEC, PONI-Guan NP/siRNA inhibits Arg I/II expression, even in the presence of TNF-α. In ASM, TNF-α increases in BDNF secretion and ECM deposition are blunted by NP-delivered siRNA. PCLS and mouse lung function studies show contractility to MCh: effects suppressed by NP-delivered BDNF and Arg I siRNA. Conclusions: Our studies show the importance of BDNF/Arginase pathways in airway remodeling and efficacy of PONI-based siRNA delivery vectors in blunting remodeling processes.

Importance Use of modern neoadjuvant chemotherapy (NAC) regimens has markedly increased rates of pathologic complete response (pCR) in breast cancer, raising the question of whether surgical removal of the primary tumor is required for patients with pCR. For surgery to be omitted, one must be able to accurately predict pCR before surgery. Objective To investigate if adding post-NAC core needle biopsy of the tumor bed to trimodality imaging in patients who have clinical complete response (cCR) will predict pCR (resolution of both invasive disease and ductal carcinoma in situ) in 90% or more cases. Design, Setting, and Participants This was a phase 2, prospective, nonrandomized clinical trial. Patients were enrolled from August 2017 to June 2019. This is the final analysis, which was completed in December 2023. The setting included academic and community hospital center members of NRG (ie, the National Surgical Adjuvant Breast and Bowel Project, the Radiation Therapy Oncology Group, and the Gynecologic Oncology Group) in the US and Canada. Patients with operable (T1-T3, stage I-III) invasive ductal carcinoma who completed NAC and achieved cCR and radiological complete response (rCR) or near rCR by mammography (mass ≤1 cm and no malignant microcalcifications), ultrasound (mass ≤2 cm), and magnetic resonance imaging (no mass with rapid rise or washout kinetics). Interventions Patients underwent marker-directed stereotactic multiple-core needle biopsy of the tumor bed with marker placement before breast-conservation surgery. Main Outcomes and Measures End points were negative predictive value (NPV) and sensitivity of the biopsy. Results A total of 105 patients were enrolled with 101 evaluable (mean [SD] age, 52.8 [10.5] years); 77 patients (76.2%) were younger than 60 years, and all breast cancer subtypes were represented with 32 (31.7%) triple-negative breast cancer, 21 (20.8%) hormone receptor–positive/epidermal growth factor receptor 2 ( ERBB2 ; formerly HER2 )–negative ( ERBB2 −) breast cancer, and 46 (45.5%) ERBB2 -positive ( ERBB2 +) breast cancer. In 101 evaluable patients, 36 had residual disease at surgery (pCR = 64%). With imaging criteria, NPV of the biopsy was 78.3% (95% CI, 67.9%-86.6%), and the sensitivity of the biopsy was 50% (95% CI, 32.9%-67.1%). In an exploratory subset analysis, the NPV in patients with ERBB2 + breast cancer was 90% (95% CI, 76.3%-97.2%). On retrospective central review, 62 of 101 enrolled patients met imaging eligibility criteria. In this exploratory post hoc analysis, NPV in these patients was 86.8% (95% CI, 74.7%-94.5%). Conclusions and Relevance These findings do not support breast conservation treatment without surgery based on the study criteria for cCR and rCR/near rCR by trimodality imaging and negative tumor-bed biopsy. Strict adherence to imaging criteria may be required to achieve acceptable predictive values. TRIAL Registration ClinicalTrials.gov Identifier: NCT03188393

Background Falls in people with multiple sclerosis (pwMS) lead to morbidity and expense. Objective Identify clinical metrics associated with falls. Methods Eighty-six pwMS completed fall surveys, timed 25-foot walk (T25FW), and motion analysis with Clario Opal devices. Logistic regression models were created. Results Median age was 54.5 years (range 21–73), 62% (53) were female. The cohort included 58% with relapsing (50) and 42% with progressive MS (36). Those who reported falling in the last year were older (median age 58 vs 52.5, p = .03) and had a higher Patient Determined Disease Step (PDDS) score (median 3 vs 1, p < .0001). Falls were associated with worse balance metrics including sway area (median 2.3 degrees 2 vs 1.2, p = .01), jerk (median 3.3 m 2 /s 5 vs 1.6, p = .005), and slower T25FW (median 11.5 s vs 8; p < .0001). A multivariable regression model based on gait aid use and T25FW time >10.8 s (c = 0.80) was derived. Having both features portended a probability of falling of 0.97, while having neither, a probability of 0.26. Conclusions Falls in pwMS are more frequent in patients who are older, have higher PDDS, slower walking, and worse balance. Gait aid use and T25FW >10.8 s were strongly associated with falls in the past year.

Background: Immediate lymphatic reconstruction (ILR) via lymphovenous anastomosis is performed in patients undergoing axillary lymph node dissection (ALND) to minimize the risk of lymphedema. Following ALND, drains are placed to prevent seromas, while prolonged drain days are associated with increased risk of infection. The study aim was to determine the impact of ILR on the number of drain days following ALND in patients with breast cancer. Methods: We report a post-hoc analysis of a prospective trial (April 2018-January 2023) comparing patients with breast cancer who underwent ALND with ILR (intervention arm) vs ALND without ILR (control arm). Wilcoxon rank sum test and chi-squared or Fisher’s exact tests compared continuous and categorical variables, respectively. Multivariable quantile regression models evaluated the difference in drain days and days until drain removal criteria were met with covariates adjusted. Results: Data from 214 patients were analyzed (n = 115 interventional arm, n = 99 control arm). The intervention arm had a median of 15 axillary drain days compared to 11 days in the control arm ( P = .001). There was no significant difference between groups when measuring drain days based on the date the drain met removal criteria, rather than actual drain removal date. Seroma incidence was lower in the intervention arm (3.5%) vs the control arm (12.1%) ( P = .017) without a statistical difference in incidence of infection. Conclusion: ALND with ILR does not decrease the number of drain days compared to ALND without ILR in patients with breast cancer, although we found the incidence of seromas to be lower without increase in incidence of infection.

Ultrasound-guided peripheral vascular access was rarely used by Certified Registered Nurse Anesthetists (CRNA) within a large academic hospital since the use of ultrasound had not been common practice among CRNAs. The purpose of this quality improvement project was to develop an educational intervention to increase the use of ultrasound for peripheral vascular access among CRNAs by 20% while also improving their knowledge, comfort, and confidence in using the technology. A pre-intervention survey revealed limited use of ultrasound for peripheral vascular access by practicing CRNAs, despite benefits of enhanced patient care demonstrated in the literature. The educational intervention included a virtual learning module, hands-on simulated training, and pre- and post-intervention knowledge assessments to measure CRNAs’ skills in ultrasound-guided techniques. Post-intervention results demonstrated a 64% increase in ultrasound use, with the average monthly rate of individual usage rising from 2.1 to 3.4 times. Additionally, participants’ knowledge scores improved from 52% to 82%, and they reported increased confidence with performing ultrasound-guided vascular access procedures. While certain barriers, like lack of access to ultrasound machines and time constraints persisted after the intervention, this education effectively addressed individual knowledge and skill gaps. This quality improvement project underscores the value of structured educational programs in advancing the use of ultrasound technology in healthcare. This highlights the importance of ongoing training and education to sustain and improve CRNAs’ knowledge and skills.