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Pancreatic ductal adenocarcinoma (PDAC) develops from 2 known precursor lesions: a majority (∼85%) develops from pancreatic intraepithelial neoplasia (PanIN), and a minority develops from intraductal papillary mucinous neoplasms (IPMNs). Clinical classification of PanIN and IPMN relies on a combination of low-resolution, 3-dimensional (D) imaging (computed tomography, CT), and high-resolution, 2D imaging (histology). The definitions of PanIN and IPMN currently rely heavily on size. IPMNs are defined as macroscopic: generally >1.0 cm and visible in CT, and PanINs are defined as microscopic: generally <0.5 cm and not identifiable in CT. As 2D evaluation fails to take into account 3D structures, we hypothesized that this classification would fail in evaluation of high-resolution, 3D images. To characterize the size and prevalence of PanINs in 3D, 47 thick slabs of pancreas were harvested from grossly normal areas of pancreatic resections, excluding samples from individuals with a diagnosis of an IPMN. All patients but one underwent preoperative CT scans. Through construction of cellular resolution 3D maps, we identified >1400 ductal precursor lesions that met the 2D histologic size criteria of PanINs. We show that, when 3D space is considered, 25 of these lesions can be digitally sectioned to meet the 2D histologic size criterion of IPMN. Re-evaluation of the preoperative CT images of individuals found to possess these large precursor lesions showed that nearly half are visible on imaging. These findings demonstrate that the clinical classification of PanIN and IPMN fails in evaluation of high-resolution, 3D images, emphasizing the need for re-evaluation of classification guidelines that place significant weight on 2D assessment of 3D structures.

Pancreatic intraepithelial neoplasias (PanINs) are the most common precursors of pancreatic cancer, but their small size and inaccessibility in humans make them challenging to study1. Critically, the number, dimensions and connectivity of human PanINs remain largely unknown, precluding important insights into early cancer development. Here, we provide a microanatomical survey of human PanINs by analysing 46 large samples of grossly normal human pancreas with a machine-learning pipeline for quantitative 3D histological reconstruction at single-cell resolution. To elucidate genetic relationships between and within PanINs, we developed a workflow in which 3D modelling guides multi-region microdissection and targeted and whole-exome sequencing. From these samples, we calculated a mean burden of 13 PanINs per cm3and extrapolated that the normal intact adult pancreas harbours hundreds of PanINs, almost all with oncogenic KRAShotspot mutations. We found that most PanINs originate as independent clones with distinct somatic mutation profiles. Some spatially continuous PanINs were found to contain multiple KRASmutations; computational and in situ analyses demonstrated that different KRASmutations localize to distinct cell subpopulations within these neoplasms, indicating their polyclonal origins. The extensive multifocality and genetic heterogeneity of PanINs raises important questions about mechanisms that drive precancer initiation and confer differential progression risk in the human pancreas. This detailed 3D genomic mapping of molecular alterations in human PanINs provides an empirical foundation for early detection and rational interception of pancreatic cancer.

Due to its poor prognosis and the late stage at which it is typically diagnosed, early detection of pancreatic cancer is a pressing clinical problem. Advances in genomic analysis of human pancreatic tissue and other biospecimens such as pancreatic cyst fluid, pancreatic juice and blood have opened the possibility of DNA-based molecular approaches for early detection of pancreatic cancer. In this Review, we discuss and focus on the pathological and molecular features of precancerous lesions of the pancreas, including pancreatic intraepithelial neoplasia, intraductal papillary mucinous neoplasm and mucinous cystic neoplasm, which are target lesions of early detection approaches. We also discuss the most prevalent genetic alterations in these precancerous lesions, including somatic mutations in the oncogenes KRASand GNASas well as tumour suppressor genes CDKN2A, TP53and SMAD4. We highlight the latest discoveries related to genetic heterogeneity and multifocal neoplasia in precancerous lesions. In addition, we review specific approaches, challenges and clinically available assays for early detection of pancreatic cancer using DNA-based molecular techniques. Although detection and risk stratification of precancerous pancreatic neoplasms are difficult problems, progress in this field highlights the promise of molecular approaches for improving survival of patients with this disease.

Intraductal tubulopapillary neoplasm (ITPN) is a distinct precancerous lesion in the pancreas with unique clinical and molecular features. Although in vitro studies in two-dimensional culture have led to numerous important insights in pancreatic cancer, such models are currently lacking for precancerous lesions. In this study, we report the generation and characterization of a cell line from a human pancreatic ITPN. Neoplastic cells were initially cultured in a three-dimensional organoid system, followed by transfer to two-dimensional culture. RNA sequencing revealed a gene expression profile consistent with pancreatic ductal origin, and whole genome sequencing identified many somatic mutations (including in genes involved in DNA repair and Wnt signaling) and structural rearrangements. In vitro characterization of the tumorigenic potential demonstrated a phenotype between that of normal pancreatic ductal cells and cancer cell lines. This cell line represents a valuable resource for interrogation of unique ITPN biology, as well as precancerous pancreatic lesions more generally.

The amenity arms race among post-secondary institutions is driving the new development or expansion of campus recreation facilities. However, investing in new and larger campus recreation facilities may not necessarily translate into usage and ultimately provide the associated benefits to students. This study explored whether human resource capacity and program capacity are mechanisms that help explain the conditions under which facility capacity translates into facility usage. Secondary data were obtained from NIRSA's research and assessment initiative from post-secondary institutions in the United States (n= 103) that contained measures of relevance to this study. Regression analyses with bootstrapping were conducted to examine the hypothesized relationships including mediation. Results identified that an indirect only mediation model (full mediation) was present, such that greater facility capacity translates into increased facility usage through human resource capacity and program capacity. Therefore, recreation professionals and programs are indicated as pivotal to making the most of facility capacity.

Pancreatic cancer is currently the third leading cause of cancer death in the United States. The clinical hallmarks of this disease include abdominal pain that radiates to the back, the presence of a hypoenhancing intrapancreatic lesion on imaging, and widespread liver metastases. Technologies such as tissue clearing and three-dimensional (3D) reconstruction of digitized serially sectioned hematoxylin and eosin-stained slides can be used to visualize large (up to 2- to 3-centimeter cube) tissues at cellular resolution. When applied to human pancreatic cancers, these 3D visualization techniques have provided novel insights into the basis of a number of the clinical characteristics of this disease. Here, we describe the clinical features of pancreatic cancer, review techniques for clearing and the 3D reconstruction of digitized microscope slides, and provide examples that illustrate how 3D visualization of human pancreatic cancer at the microscopic level has revealed features not apparent in 2D microscopy and, in so doing, has closed the gap between bench and bedside. Compared with animal models and 2D microscopy, studies of human tissues in 3D can reveal the difference between what can happen and what does happen in human cancers.

Pancreatic intraductal papillary mucinous neoplasms (IPMNs) have gained substantial attention because they represent one of the only radiographically identifiable precursors of invasive pancreatic ductal adenocarcinoma. Although most of these neoplasms have low-grade dysplasia and will remain indolent, a subset of IPMNs will progress to invasive cancer. The role of the immune system in the progression of IPMNs is unclear, but understanding its role could reveal the mechanism of neoplastic progression and targets for immunotherapy to inhibit progression or treat invasive disease. The available evidence supports a shift in the immune composition of IPMNs during neoplastic progression. Although low-grade lesions contain a high proportion of effector T cells, high-grade IPMNs, and IPMNs with an associated invasive carcinoma lose the T-cell infiltrate and are characterised by a predominance of immunosuppressive elements. Several possible therapeutic strategies emerge from this analysis that are unique to IPMNs and its microbiome.

A central challenge in biology is obtaining high-content, high-resolution information while analyzing tissue samples at volumes relevant to disease progression. We address this here with CODA, a method to reconstruct exceptionally large (up to multicentimeter cubed) tissues at subcellular resolution using serially sectioned hematoxylin and eosin-stained tissue sections. Here we demonstrate CODA’s ability to reconstruct three-dimensional (3D) distinct microanatomical structures in pancreas, skin, lung and liver tissues. CODA allows creation of readily quantifiable tissue volumes amenable to biological research. As a testbed, we assess the microanatomy of the human pancreas during tumorigenesis within the branching pancreatic ductal system, labeling ten distinct structures to examine heterogeneity and structural transformation during neoplastic progression. We show that pancreatic precancerous lesions develop into distinct 3D morphological phenotypes and that pancreatic cancer tends to spread far from the bulk tumor along collagen fibers that are highly aligned to the 3D curves of ductal, lobular, vascular and neural structures. Thus, CODA establishes a means to transform broadly the structural study of human diseases through exploration of exhaustively labeled 3D microarchitecture.

Therapeutic circus arts (TCA) present a new arena for drama therapy, capitalizing on the historical connection between circus and theatre arts. To evaluate whether drama therapy core processes also present in TCA, we conduct a qualitative content analysis of research articles centred on TCA (N= 40). Selected articles were thematically coded, showing that all of drama therapy’s core processes also appear in the TCA literature. Of those processes, ‘empathy and distancing’, ‘play’, ‘life-drama connection’ and ‘transformation’ were especially prominent. Implications include the potential for knowledge sharing and future collaboration between the TCA and drama therapy fields.

This article describes and documents a step-by-step, iterative process of competency modelling – a way of identifying, generating and disseminating professional knowledge-based competencies in the field of drama therapy. The authors, the Education Competency Team (ETC) designated by the North American Drama Therapy Association (NADTA) board, discuss the significance of and the need for knowledge competencies, as well as the importance of transparency in their design. Relevant literature defining competency-based learning, its connection to skill, employment and equity, as well as a detailed outline of the three-tiered recursive method used collaboratively to create this inaugural document are included. We conclude with a discussion of limitations and future directions for the model, which also evidences as a living document.

The purpose of this study was to explore how students’ knowledge of campus recreation opportunities and their general physical activity (PA) motivations were associated with participation or non-participation in intramural sports, drop-in sports, and the fitness center. Data were collected using a questionnaire from undergraduate students (N = 348) at a large university in Ontario, Canada. Data were analyzed using logistic regression. Knowledge of opportunities was positively associated with participation in all three campus recreation activities. A desire to enhance the university experience was positively associated with intramurals and drop-in sports. Additionally, a desire to be fit through PA was negatively associated with drop-in sports. In addition to increasing students’ knowledge of opportunities, recreation professionals are encouraged to identify and promote the unique aspects of the campus recreation experience, such as its ability to enhance the university experience, in order to stimulate participation through differentiation from off-campus recreation experiences.

To test the hypothesis that autoimmune hepatitis (AIH type I) in young subjects is due to genetic differences in proinflammatory genes responding to viral triggers in patients and controls. Intrahepatic gene expression was compared between AIH type I (n = 24, age 9–30 years) patients (hereafter referred to as the AIH group) and controls (n = 21, age 4–25 years). RNA sequencing was performed on complementary DNA (cDNA) libraries made from total RNA extracted from formalin-fixed paraffin-embedded (FFPE) liver biopsy samples. Gene expression levels were quantified, and differentially expressed genes were functionally analyzed. Pathway analysis was performed using the databases Kyoto Encyclopedia of Genes and Genomes (KEGG) and PANTHER. The remaining sequences were mapped to the RefSeq complete set of viral genomes. Differential gene analysis identified 181 genes that were significantly differentially expressed (136 upregulated in the AIH group). Autoimmune pathway genes such as CD19and CD20which are important in B cell regulation and maturation as well as, CD8and LY9, which are T-cell related, were upregulated in our AIH group. Genes implicated in AIH pathogenesis including CXCL10, which is thought to be associated with AIH severity and progression, complement genes (C1QA, C1QB, and C1QC), and human leucocyte antigen (HLA) genes (HLA-DRB1, HLA-DRA, HLA-B, and HLA-C) were upregulated in samples from the AIH group. Specific viral etiologies were not found. Unbiased next-generation sequencing and differential gene expression analysis of the AIH group has not only added support for the role of B cells in the pathogenesis and treatment of AIH but also has introduced potential new therapeutic targets: CXCL10(anti-CXCL10) and several complement system–related genes.

This study introduces a new imaging, spatial transcriptomics (ST), and single-cell RNA-sequencing integration pipeline to characterize neoplastic cell state transitions during tumorigenesis. We applied a semi-supervised analysis pipeline to examine premalignant pancreatic intraepithelial neoplasias (PanINs) that can develop into pancreatic ductal adenocarcinoma (PDAC). Their strict diagnosis on formalin-fixed and paraffin-embedded (FFPE) samples limited the single-cell characterization of human PanINs within their microenvironment. We leverage whole transcriptome FFPE ST to enable the study of a rare cohort of matched low-grade (LG) and high-grade (HG) PanIN lesions to track progression and map cellular phenotypes relative to single-cell PDAC datasets. We demonstrate that cancer-associated fibroblasts (CAFs), including antigen-presenting CAFs, are located close to PanINs. We further observed a transition from CAF-related inflammatory signaling to cellular proliferation during PanIN progression. We validate these findings with single-cell high-dimensional imaging proteomics and transcriptomics technologies. Altogether, our semi-supervised learning framework for spatial multi-omics has broad applicability across cancer types to decipher the spatiotemporal dynamics of carcinogenesis.

Pancreatic cancer is one of the most lethal cancer types, estimated to become the second leading cause of cancer-related deaths in the United States in 2030. The use of 3-dimensional culture systems has greatly expanded over the past few years, providing a valuable tool for the study of pancreatic cancer. In this review, we highlight some of the preclinical in vitro and in vivo models used in pancreatic cancer research, each with its own advantages and disadvantages, and focus on one of the recently used 3-dimensional culture models: organoids. Organoids are multicellular units derived from tissue samples and embedded within extracellular matrix gels after mechanical and enzymatic digestion. We define organoids, differentiate them from other 3-dimensional culture systems such as spheroids, and describe some applications of this model that have recently advanced our understanding of pancreatic cancer and its tumor microenvironment. Organoids have provided valuable insights into pancreatic cancer progression, heterogeneity, and invasion, and they have enabled the creation of biobanks, providing a platform for drug screening. In addition, we discuss some of the future directions and challenges in this model when addressing research questions.

This mixed-methods study explored the impact of a theatre-based community mental health and education initiative to address racism. Comparisons were examined between participants who either just saw a musical that centred on the theme of racism, or who saw the same musical and partook in a post-show experiential workshop that used restorative justice practices and drama therapy/applied theatre exercises. The results established that participants who saw the show and attended the post-show workshop (n = 38), in comparison to participants who only saw the show (n = 69), significantly (p = .001) agreed that the combined experience allowed them to reflect on biases and other forms of discrimination. Researchers also discovered that age and gender yielded considerable differences across groups. Additionally, there were five themes that were derived from the applied thematic analysis. Participants reported: (1) increased knowledge; (2) that they felt emotions; (3) that they connected with others; (4) that they experienced personal transformation in the here and now; and (5) that they were inspired to enact change. These qualitative themes supported quantitative analysis, which concluded that, while the theatre experience alone was impactful, the workshop augmented the central message and cultivated participants’ deeper reflections.

Immune checkpoint inhibitors, such as programmed cell death ligand 1 inhibitors pembrolizumab, nivolumab, atezolizumab, and avelumab, are used to treat patients with advanced urothelial carcinoma (UC). Based on data from the phase 3 JAVELIN Bladder 100 trial, avelumab first-line (1L) maintenance is now considered the standard-of-care treatment for patients with locally advanced or metastatic UC who responded or experienced disease stabilization after 1L platinum-containing chemotherapy, and it is the only category 1 preferred checkpoint inhibitor maintenance option in the National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology for patients with cisplatin-eligible and cisplatin-ineligible locally advanced or metastatic UC. This article reviews key considerations related to avelumab 1L maintenance therapy that infusion nurses should be familiar with, including dosing, administration, and immune-related adverse event recognition and management, to ensure safe and appropriate use of this important and impactful therapy.

This article reviews several key aspects of the Theory of Active and Latent Failures, typically referred to as the Swiss cheese model of human error and accident causation. Although the Swiss cheese model has become well known in most safety circles, there are several aspects of its underlying theory that are often misunderstood. Some authors have dismissed the Swiss cheese model as an oversimplification of how accidents occur, whereas others have attempted to modify the model to make it better equipped to deal with the complexity of human error in health care. This narrative review aims to provide readers with a better understanding and greater appreciation of the Theory of Active and Latent Failures upon which the Swiss cheese model is based. The goal is to help patient safety professionals fully leverage the model and its associated tools when performing a root cause analysis as well as other patient safety activities.

This review, based on the content of the 2020 US Gastrointestinal Pathology Society’s Rodger Haggitt Lecture, concerns an array of tubular gastrointestinal tract dysplastic or possible “predysplastic lesions” with an almost purely morphologic focus based on our collaborative efforts over the past few years. These processes include esophageal epidermoid metaplasia, Barrett esophagus-associated dysplasia, polypoid gastric dysplastic lesions, small intestinal dysplasia, and the ability of metastases to mimic it, the controversial “serrated epithelial change” encountered in the setting of long-standing ulcerative and Crohn colitis, and recently described anal columnar human papilloma virus-associated neoplasms.

Familial adenomatous polyposis (FAP) is an inherited cancer predisposition syndrome associated with numerous gastrointestinal tract adenomatous polyps, as well as gastric fundic gland polyps and pyloric gland adenomas in the upper gastrointestinal tract. While colonic FAP-associated traditional serrated adenomas (TSAs) have been reported in a few studies, small bowel FAP-associated adenomas with TSA morphology have not been characterized. This study describes the clinicopathologic and molecular findings of this type of adenoma in the small bowel of patients with FAP. We reviewed small bowel adenomas in 45 consecutive FAP patients to identify adenomas with zones showing slit-like serrations, cells with eosinophilic cytoplasm, ectopic crypt formation, and vesicular nuclei. Sporadic small bowel adenomas from 51 consecutive patients were also reviewed for adenomas with the same features. Of the 177 polyps from 45 FAP patients and 60 polyps from 51 nonsyndromic patients, 18 TSAs from 9 FAP patients (20%) and 10 TSAs from the sporadic group (19.6%) were identified. FAP patients presented at a younger age than nonsyndromic patients (median: 43 vs. 66; P=0.0048). FAP-associated TSAs were asymptomatic and smaller than sporadic TSAs (median size: 0.6 vs. 2.5 cm; P=0.00006). Immunostaining for β-catenin and testing for BRAFand KRASmutations were performed in a subset of the cohort. Nuclear β-catenin was seen in 1 FAP-associated TSA and 3 nonsyndromic TSAs. All TSAs (FAP-associated and nonsyndromic) showed wild-type BRAF, while KRASmutations were identified only in the nonsyndromic setting. In summary, small bowel FAP-associated and sporadic TSAs share a similar morphology, and the BRAF-serrated pathway does not contribute to their pathogenesis.

The global population of unaccompanied minors—children and adolescents younger than 18 years who migrate without their legal guardians—is increasing. However, as data are not systematically collected in any region, if collected at all, little is known about this diverse group of young people. Compared with adult migrants, unaccompanied minors are at greater risk of harm to their health and integrity because they do not have the protection provided by a family, which can affect their short-term and long-term health. This Review summarises evidence regarding the international migration and health of unaccompanied minors. Unaccompanied minors are entitled to protection that should follow their best interests as a primary consideration; however, detention, sometimes under the guise of protection, is a widespread practice. If these minors are provided with appropriate forms of protection, including health and psychosocial care, they can thrive and have good long-term outcomes. Instead, hostile immigration practices persist, which are not in the best interests of the child.

Root Cause Analysis and Action (RCA2) guidelines offer fundamental improvements to traditional RCA. Yet, these guidelines lack robust methods to support a human factors analysis of patient harm events and the development of systems-level interventions. We previously described how human factors tools can be integrated into RCA2to create a robust process called HFACS-RCA2. Prior analyses of qualitative data associated with an 18-month implementation project at a large academic health center indicated that HFACS-RCA2fosters a more comprehensive human factors analysis of serious patient harm events and the identification of broader system interventions. The present study builds on this prior research by presenting the analysis of actual recommendations extracted from RCA reports. Results corroborate qualitative stakeholder findings that HFACS-RCA2produced recommendations that were stronger and included more substantive changes compared to former RCA methods.

AbstractThe Daily Life Experiences – Frequency scale (DLE-F) measures the frequency of 18 racial discrimination experiences. Bifactor exploratory and confirmatory analyses indicated that the DLE-F is a unidimensional scale that yields valid and reliable scores. The DLE-F also showed evidence of measurement invariance by gender, convergent evidence, and criterion-related validity.

The purpose of this study was to explore the differential effects of constraints on participation in three different types of campus recreation (i.e., intramural sports, drop-in sports, fitness center), and how constraints differ based on gender and citizenship. Data were collected from undergraduate students (n= 344) using a questionnaire at a large university in Ontario, Canada and analyzed using logistic regression and Mann–Whitney U. Non-participation in intramurals was associated with not knowing how to get involved, drop-in sports with not knowing enough people to participate, and fitness center with feeling uncomfortable exercising in public. Women and men did not differ in the ten constraints measured in the study. International students were more constrained than domestic students by feeling as though the recreation facilities were inaccessible. Implications for practice are discussed.

ObjectiveRecently, tumours with microsatellite instability (MSI)/defective DNA mismatch repair (dMMR) have gained considerable interest due to the success of immunotherapy in this molecular setting. Here, we aim to clarify clinical-pathological and/or molecular features of this tumour subgroup through a systematic review coupled with a comparative analysis with existing databases, also providing indications for a correct approach to the clinical identification of MSI/dMMR pancreatic ductal adenocarcinoma (PDAC).DesignPubMed, SCOPUS and Embase were searched for studies reporting data on MSI/dMMR in PDAC up to 30 November 2019. Histological and molecular data of MSI/dMMR PDAC were compared with non-MSI/dMMR PDAC and with PDAC reference cohorts (including SEER database and The Cancer Genome Atlas Research Network - TCGA project).ResultsOverall, 34 studies with 8323 patients with PDAC were included in the systematic review. MSI/dMMR demonstrated a very low prevalence in PDAC (around 1%–2%). Compared with conventional PDAC, MSI/dMMR PDAC resulted strongly associated with medullary and mucinous/colloid histology (p<0.01) and with a KRAS/TP53wild-type molecular background (p<0.01), with more common JAKgenes mutations. Data on survival are still unclear.ConclusionPDAC showing typical medullary or mucinous/colloid histology should be routinely examined for MSI/dMMR status using specific tests (immunohistochemistry, followed by MSI-PCR in cases with doubtful results). Next-generation sequencing (NGS) should be adopted either where there is limited tissue or as part of NGS tumour profiling in the context of precision oncology, acknowledging that conventional histology of PDAC may rarely harbour MSI/dMMR.

ObjectiveIntraductal papillary mucinous neoplasms (IPMNs) are non-invasive precursor lesions that can progress to invasive pancreatic cancer and are classified as low-grade or high-grade based on the morphology of the neoplastic epithelium. We aimed to compare genetic alterations in low-grade and high-grade regions of the same IPMN in order to identify molecular alterations underlying neoplastic progression.DesignWe performed multiregion whole exome sequencing on tissue samples from 17 IPMNs with both low-grade and high-grade dysplasia (76 IPMN regions, including 49 from low-grade dysplasia and 27 from high-grade dysplasia). We reconstructed the phylogeny for each case, and we assessed mutations in a novel driver gene in an independent cohort of 63 IPMN cyst fluid samples.ResultsOur multiregion whole exome sequencing identified KLF4, a previously unreported genetic driver of IPMN tumorigenesis, with hotspot mutations in one of two codons identified in >50% of the analyzed IPMNs. Mutations in KLF4were significantly more prevalent in low-grade regions in our sequenced cases. Phylogenetic analyses of whole exome sequencing data demonstrated diverse patterns of IPMN initiation and progression. Hotspot mutations in KLF4were also identified in an independent cohort of IPMN cyst fluid samples, again with a significantly higher prevalence in low-grade IPMNs.ConclusionHotspot mutations in KLF4occur at high prevalence in IPMNs. Unique among pancreatic driver genes, KLF4mutations are enriched in low-grade IPMNs. These data highlight distinct molecular features of low-grade and high-grade dysplasia and suggest diverse pathways to high-grade dysplasia via the IPMN pathway.

Ipilimumab plus nivolumab has been approved for intermediate- and poor-risk metastatic renal cell carcinoma (RCC). However, the activity in non–clear cell RCC (nccRCC) is unknown.