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The article discusses a study that looked at the caries experienced by various students at the State College of Washington. A synopsis of the study is presented, which included a description of the students involved with the study. Differences that were found in the number of dental caries experienced in students from different areas of the state are discussed.

The article presents a case study of a 62 year old female diagnosed with complex perianal disease and Crohn's colitis in April 2010. In July 2011, the patient's clinical examination revealed a pyrexia, tachycardia and marked suprapubic tenderness and the abdominal x-ray discovered faecal loading in transverse and ascending colon. The histology confirmed active chronic Crohn's colitis. The postoperative recovery was dull and adalimumab for induction and maintenance therapy was started up.

Context: There is a lack of reliable biomarkers capable of predicting postoperative tumor progression of nonfunctioning pituitary adenomas (NFPAs)., Objective: To discover proteomic profiles associated with postoperative tumor progression in patients with NFPAs. This was a case-controlled exploratory study at a tertiary university hospital. Tissue samples were obtained from 46 patients with residual tumor following surgery for NFPAs of gonadotroph lineage. Two patient groups were compared: patients requiring reintervention due to residual tumor progression (cases; reintervention group, n = 29) and patients with a residual tumor showing no progression for a minimum of 5 years (controls; radiologically stable group, n = 17). Differentially expressed proteins (DEPs) between patient groups were measured., Results: Global quantitative proteomic analysis identified 4074 proteins, of which 550 were differentially expressed between the 2 groups (fold change >80%, false discovery rate-adjusted P ≤ .05). Principal component analysis showed good separation between the 2 groups. Functional enrichment analysis of the DEPs indicated processes involving translation, ROBO-receptor signaling, energy metabolism, mRNA metabolism, and RNA splicing. Several upregulated proteins in the reintervention group, including SNRPD1, SRSF10, SWAP-70, and PSMB1, are associated with tumor progression in other cancer types., Conclusion: This is the first exploratory study analyzing proteomic profiles as markers of postoperative tumor progression in NFPAs. The findings clearly showed different profiles between tumors with indolent postoperative behavior and those with postoperative tumor progression. Both enriched pathways involving DEPs and specific upregulated proteins have previously been associated with tumor aggressiveness. These results suggest the value of proteomic profiling for predicting tumor progression in patients with NFPAs., (© The Author(s) 2023. Published by Oxford University Press on behalf of the Endocrine Society.)

Evidence-based treatments have been developed for a range of pediatric mental health conditions. These interventions have proven efficacy but require trained pediatric behavioral health specialists for their administration. Unfortunately, the widespread shortage of behavioral health specialists leaves few referral options for primary care providers. As a result, primary care providers are frequently required to support young patients during their lengthy and often fruitless search for specialty treatment. One solution to this treatment-access gap is to draw from the example of integrated behavioral health and adapt brief evidence-based treatments for intra-disciplinary delivery by primary care providers in consultation with mental health providers. This solution has potential to expand access to evidence-based interventions and improve patient outcomes. We outline how an 8-step theory-based process for adapting evidence-based interventions, developed from a scoping review of the wide range of implementation science frameworks, can guide treatment development and implementation for pediatric behavioral health care delivery in the primary care setting, using an example of our innovative treatment adaptation for child and adolescent eating disorders. After reviewing the literature, obtaining input from leaders in eating disorder treatment research, and engaging community stakeholders, we adapted Family-Based Treatment for delivery in primary care. Pilot data suggest that the intervention is feasible to implement in primary care and preliminary findings suggest a large effect on adolescent weight gain. Our experience using this implementation framework provides a model for primary care providers looking to develop intra-disciplinary solutions for other areas where specialty services are insufficient to meet patient needs., Competing Interests: Declaration of Competing Interest Dr. Le Grange receives royalties from Guilford Press and Routledge. He also is Co-Director of the Training Institute for Child and Adolescent Eating Disorders, LLC. Dr. Loeb is also a faculty member at the Training Institute for Child and Adolescent Eating Disorders LLC. The other authors have indicated they have no financial relationships relevant to this article or potential conflicts of interest to disclose., (Copyright © 2024 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Objective: The impact of conduit dimensions and location of esophagogastric anastomosis on long-term quality of life after esophagectomy remains unexplored. We investigated the association of these parameters with surgical outcomes and patient-reported quality of life at least 18 months after esophagectomy., Methods: We identified all patients who underwent esophagectomy for cancer from 2018 to 2020 in our institution. We reviewed each patient's initial postoperative computed tomography scan measuring the gastric conduit's greatest width (centimeters), linear staple line length (centimeters), and relative location of esophagogastric anastomosis (vertebra). Quality of life was ascertained using patient-reported outcome measures. Perioperative complications, length of stay, and mortality were collected. Multivariate regressions were performed., Results: Our study revealed that a more proximal anastomosis was linked to an increased risk of pulmonary complications, a lower recurrence rate, and greater long-term insomnia. Increased maximum intrathoracic conduit width was significantly associated with trouble enjoying meals and reflux long term after esophagectomy. A longer conduit stapled line correlated with fewer issues related to insomnia, improved appetite, less dysphagia, and significantly enhanced "social," "role," and "physical'" aspects of the patient's long-term quality of life., Conclusions: The dimensions of the gastric conduit and the height of the anastomosis may be independently associated with outcomes and long-term quality of life after esophagectomy for cancer., Competing Interests: The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (© 2023 The Author(s).)

Antibody-drug conjugates unite the specificity and long circulation time of an antibody with the toxicity of a chemical cytostatic or otherwise active drug using appropriate chemical linkers to reduce systemic toxicity and increase therapeutic index. This combination of a large biological molecule and a small molecule creates an increase in complexity. Multiple production processes are required to produce the native antibody, the drug and the linker, followed by conjugation of afore mentioned entities to form the final antibody-drug conjugate. The connected processes further increase the number of points of control, resulting in necessity of additional specifications and intensified analytical characterization. By combining scientific understanding of the production processes with risk-based approaches, quality can be demonstrated at those points where control is required and redundant comparability studies, specifications or product characterization are avoided. Over the product development lifecycle, this will allow process qualification to focus on those areas critical to quality and prevent redundant studies. The structure of the module 3 common technical document for an ADC needs to reflect each of the production processes and the combined overall approach to quality. Historically, regulatory authorities have provided varied expectations on its structure. This paper provides an overview of essential information to be included and shows that multiple approaches work as long as adequate cross-referencing is included., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023. Published by Elsevier Inc.)

Introduction: Solitary pulmonary nodules (SPNs) are common, but the clinical relevance of these nodules is unknown. Utilizing current screening guidelines, we sought to better characterize the national incidence of clinically important SPNs within the largest universal health care system in the nation., Materials and Methods: TRICARE data were queried to identify SPNs for ages 18-64 years. SPNs that had been diagnosed within a year with no prior oncologic history were included to ensure true incidence. A proprietary algorithm was applied to determine clinically significant nodules. Further analysis characterized incidence by age grouping, gender, region, military branch, and beneficiary status., Results: A total of 229,552 SPNs were identified with a 60% reduction seen after application of the clinical significance algorithm (N = 88,628). The incidence increased in each decade of life (all P < 0.01). Adjusted incident rate ratios were significantly higher for SPNs detected in the Midwest and Western regions. The incident rate ratio was also higher in females (1.05, confidence interval [CI] 1.018, P = 0.001) as well as non-active duty members (dependents = 1.4 and retired = 1.6, respectively, CIs 1.383-1.492 and 1.591-1.638, P < 0.01). The incidence calculated per 1,000 patients overall was 3.1/1,000. Ages 44-54 years had an incidence of 5.5/1,000 patients, which is higher than the previously reported incidence of < 5.0 nationally for the same age group., Conclusions: This analysis represents the largest evaluation of SPNs to date combined with clinical relevance adjustment. These data suggest a higher incidence of clinically significant SPNs starting at an age of 44 years in nonmilitary or retired women localized to the Midwest and Western regions of the United States., (© The Association of Military Surgeons of the United States 2023. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

A validated open-source deep-learning algorithm called Sybil can accurately predict long-term lung cancer risk from a single low-dose chest computed tomography (LDCT). However, Sybil was trained on a majority-male cohort. Use of artificial intelligence algorithms trained on imbalanced cohorts may lead to inequitable outcomes in real-world settings. We aimed to study whether Sybil predicts lung cancer risk equally regardless of sex. We analyzed 10,573 LDCTs from 6127 consecutive lung cancer screening participants across a health system between 2015 and 2021. Sybil achieved AUCs of 0.89 (95% CI: 0.85-0.93) for females and 0.89 (95% CI: 0.85-0.94) for males at 1 year, p = 0.92. At 6 years, the AUC was 0.87 (95% CI: 0.83-0.93) for females and 0.79 (95% CI: 0.72-0.86) for males, p = 0.01. In conclusion, Sybil can accurately predict future lung cancer risk in females and males in a real-world setting and performs better in females than in males for predicting 6-year lung cancer risk., (© 2023. The Author(s).)

Background: Integrating tobacco treatment services into lung cancer screening (LCS) has the potential to leverage a 'teachable moment' to promote cessation among long-term smokers and reduce disparities in tobacco treatment access. This protocol paper describes the Screen ASSIST (Aiding Screening Support In Stopping Tobacco) trial, which will identify how to best deliver evidence-driven tobacco treatment in the context of LCS., Methods: Screen ASSIST is a randomized clinical trial with a 3-factor, fully crossed factorial design that enrolls current smokers (any cigarette use in the past 30 days) scheduled to attend LCS at multiple sites in the Mass General Brigham healthcare system. To maximize reach, recruitment is conducted at 3 time points: 1) at the time of LCS scheduling, 2) at the LCS visit, and 3) after the participant has received their LCS results. Participants are stratified by LCS study site and recruitment point and randomly assigned into 8 groups that test intervention components varying on telehealth counseling duration (4 weeks vs. 8 weeks), nicotine replacement therapy duration (2 weeks vs. 8 weeks), and systematic screening and referral for social determinants of health via a service named 'AuntBertha' (referral vs. no referral). The primary study outcome is self-reported past 7-day tobacco abstinence at 6-month follow-up. This trial will also assess systems integration and evaluate implementation of the intervention., Discussion: Screen ASSIST will identify the most effective combination of tobacco cessation treatments within the LCS context, in order to improve the cost-effectiveness of LCS and quality of life among long-term heavy smokers., (Copyright © 2021. Published by Elsevier Inc.)

Aim: The aim of this study was to evaluate undergraduate nursing students' perceptions of using telehealth-based simulations for practicing their breastfeeding education skills., Background: Telehealth can help bridge the gap between the high need for healthcare services and the limited access to these services, such as breastfeeding mothers in rural settings. However current literature suggests that there is lack of telehealth education among healthcare providers, as well as, a shortage of adequately trained nurses on breastfeeding, making it difficult to provide new mothers with the support they need to successfully breastfeed. Telehealth simulation has shown to be acceptable and helpful in teaching clinical reasoning, increasing exposure to telehealth experiences, and preparing nursing students for real interaction experiences with patients., Design: For this cross-sectional descriptive study, two breastfeeding telehealth simulation scenarios were developed and delivered through Zoom for Bachelor of Science in Nursing students in a high-level institution in Florida. Selected students interacted over Zoom as healthcare providers with a female simulated patient who played as a mother with a breastfeeding concern. Students in their role of healthcare providers assessed the breastfeeding needs of the mother and conducted breastfeeding education as appropriate. After debriefing, students received feedback from faculty and students who observed the simulation and completed an optional evaluation about their telehealth simulated experience., Results: A total of 205 students completed the evaluation. Most students (n = 136, 66.3%) were not familiar with telehealth prior to the simulation. Most students (n = 199, 97.1%) also found the simulation helpful for supporting breastfeeding mothers and wanted more telehealth simulations in the future (n = 162, 79%). Feedback for improving the simulations included: improving the technical setup (n = 17, 8.3%), increasing the time that students interacted with the mother (n = 16, 7.8%), and observing the correct performance of the simulation after debriefing (n = 16, 7.8%)., Conclusion: Telehealth simulation is a promising modality for clinical competency assessment, thus it is essential to integrate telehealth education into nursing curriculum. It is evident that telehealth-based breastfeeding simulations can be used to address the exposure/knowledge gap among nursing students who are missing or have limited exposure to breastfeeding content and telehealth use in their nursing curriculum., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Objectives: Literature shows that sexual activity remains important at older age and is a valued part of life. However, little is known about the intimate partner relationships (IPR) among minority older women living with Human Immunodeficiency Virus (HIV). The purpose of this study is to explore the effect HIV diagnosis had on the intimate partner relationships (IPR) among minority older women living with HIV (MOWH)., Methods: Qualitative descriptive study. A total of 28 MOWH (Black and Latinas) aged 50 years and older participated in face to face semi-structured in-depth interviews. Interviews were analyzed using content analysis., Results: Three themes emerged from the analysis: (a)" Intimate partner relationships before HIV diagnosis" that revealed sexual practices increasing the risk for HIV in their intimate relationships; (b)" Facing relationship consequences of HIV disclosure after diagnosis" explored the consequences of HIV disclosure, and how disclosure determined the future of their intimate relationships; and (c) "Intimate partner relationships after HIV diagnosis" described the quality of intimate partner relationships and changes after HIV diagnosis., Conclusions: Results from this study contribute to understanding and increasing awareness of the effect of HIV on the intimacy of MOWH., Clinical Implications: Education provided by health care workers and interventions targeting MOWH should address the effect of HIV in IPR, address MOWH's concerns about it, and help them to improve their overall health.

Objectives: Aspirations are common after esophagectomy. Data are lacking regarding its long-term radiological manifestations. The purpose of this study is to determine the incidence and radiological patterns of aspirations among long-term survivors and evaluate their clinical significance., Methods: The records of all patients who underwent esophagectomy between October 2003 and December 2011 and survived more than 3 years were reviewed. Preoperative, first routine postoperative, and latest chest computed tomography (CT)scans were reviewed. Imaging studies were reviewed for radiological signs suspicious of aspirations, conduit location, anastomotic site, and maximal intrathoracic diameter. Data regarding patients' complaints during clinic visits were also collected., Results: A total of 578 patients underwent esophagectomy during the study period. One-hundred twenty patients met the inclusion criteria. Median follow-up was 83.5 months. Cervical and intrathoracic anastomoses were performed in 103 and 17 patients, respectively. A higher rate of CT findings was found in postoperative imaging ( n  = 51 [42.5%] vs. n  = 13 [10.8%] respectively, p  < 0.05). Most of these were found in the lower lobes (61%). A higher rate of lesions was found among patients in whom the conduit was bulging to the right hemithorax compared with totally mediastinal or completely in the right hemithorax (54.5 vs. 35.2% and 34.6%, respectively, p  < 0.05). No correlation was found with conduit diameter or anastomotic site. These lesions were more prevalent among patients who complained of reflux or cough during meals (NS)., Conclusions: A significantly higher rate of new CT findings was found in postoperative imaging of this post-esophagectomy cohort, suggesting a high incidence of aspirations. The locations of the conduit, rather than anastomosis site, seem to play a role in the development of these findings. Further research is needed to evaluate the clinical significance of these findings., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Thieme. All rights reserved.)

This study describes the use of a multidimensional HPLC (2D and 4D) system for a faster and more effective characterization of an antibody-drug conjugate (ADC) product, compared to the standard off-line approach of fraction collection and off-line variant characterization. The size variants of an interchain cysteine-linked ADC were characterized to understand the effect of the different drug-to-antibody ratio (DAR) species on aggregate formation. For this purpose, the ADC product and a full panel of stressed samples were analyzed. The dimeric ADC species were baseline resolved from the main peak (Rs = 2.7) by UHP-SEC (ultra-high-performance size exclusion chromatography) under nondenaturing conditions using a buffered mobile phase containing 5% 2-propanol. A 2D-LC (SEC-HIC) method was then developed to compare the average DAR values of the main peak species vs the aggregates. A 4D-LC/MS method (SEC-reduction-digestion-RPHPLC) was also developed to determine levels of potential critical quality attributes (pCQAs) including aggregation, average DAR, oxidation, and deamidation, in a 2 h run. An average DAR value of 3.5-3.6 was found for the main peak using both 2D-LC and 4D-LC methods, and these values were consistent with DAR determined by the in-house reference hydrophobic interaction chromatography (HIC) method. The multidimensional LC approaches also showed an increase in the content of high-DAR species in the SEC fractions containing the aggregates. Overall the entire workflow of data acquisition is completed within a day using the multidimensional on-line approach, in comparison to multiple days required with the traditional off-line approaches.

Background: The benefits of minimally invasive versus open thymectomy for the management of thymoma are debatable. Further, patient factors contributing to the selection of operative technique are not well elucidated. We aim to identify the association between baseline patient characteristics with choice of surgical approach., Methods: Medical records of early stage thymoma (stages I and II) patients undergoing thymectomy between 2005 and 2015 at a single center were identified. Baseline characteristics and surgical outcomes such as prolonged length of stay (LOS ≥ 4 days), 90-day postoperative morbidity, completeness of resection, and recurrence or mortality free rates were compared by surgical approach., Results: Fifty-three patients underwent thymectomy (34 open [64.15%] vs. 19 minimally invasive [35.85%]). There were no statistical differences between the two surgical approaches in demographic variables, smoking status, lung function, comorbidity, tumor size, or staging. Open thymectomy had significantly prolonged LOS (≥4 days) compared with minimally invasive procedures (odds ratio: 11.65; p  < 0.01). There were no significant differences in postoperative composite morbidity ( p  = 0.56), positive margin ( p  = 0.40), tumor within 0.1 cm of resection margin ( p  = 0.38), and survival probability estimates (log rank test; p  = 0.48) between the two groups., Conclusion: Baseline patient characteristics were not associated with surgical approach selected for thymectomy. Minimally invasive thymectomy patients had shorter LOS but no significant differences in 90-day composite morbidity and recurrence or mortality. Larger multicenter studies are needed to evaluate factors contributing to patient selection for each approach, which may include surgeon preference., Competing Interests: None., (Georg Thieme Verlag KG Stuttgart · New York.)

Peptide mapping with liquid chromatography-tandem mass spectrometry (LC-MS/MS) is an important analytical method for characterization of post-translational and chemical modifications in therapeutic proteins. Despite its importance, there is currently no consensus on the statistical analysis of the resulting data. In this manuscript, we distinguish three statistical goals for therapeutic protein characterization: (1) estimation of site occupancy of modifications in one condition, (2) detection of differential site occupancy between conditions, and (3) estimation of combined site occupancy across multiple modification sites. We propose an approach, which addresses these goals in terms of summarizing the quantitative information from the mass spectra, statistical modeling, and model-based analysis of LC-MS/MS data. We illustrate the approach using an LC-MS/MS experiment from an antibody-drug conjugate and its monoclonal antibody intermediate. The performance was compared to a 'naïve' data analysis approach, by using computer simulation, evaluation of differential site occupancy in positive and negative controls, and comparisons of estimated site occupancy with orthogonal experimental measurements of N-linked glycoforms and total oxidation. The results demonstrated the importance of replicated studies of protein characterization, and of appropriate statistical modeling, for reproducible, accurate and efficient site occupancy estimation and differential analysis.

Antibody drug conjugates (ADCs) are complex therapeutic agents combining the selectivity of monoclonal antibodies and highly efficacious small molecule drugs to successfully eliminate tumor cells while limiting the general toxicity and side effects of the therapeutic to protect patient safety. One unique attribute critical to the safety of ADCs is the residual content of unconjugated small molecule drug present from either incomplete conjugation or degradation of the ADC. Typically for quality control assays, quantifying the amount of the free drug is performed through precipitation of the protein species using an organic solvent and then assaying the amount of free drug left in the supernatant. During the validation of an assay of this type for a maleimide based linker drug, issues were experienced with low and variable recovery in the spiked samples of the drug substance and drug product. A two-dimensional heart-cutting method coupling Size Exclusion Chromatography (SEC) with Reverse Phase (RP) chromatography was utilized to explore possible mechanisms leading to the low recovery of the free linker drug. The results of the investigation indicated that the spiked linker drug reacts with residual reactive groups on the ADC; a conclusion which was confirmed by the observed increase of average Drug to Antibody Ratio (DAR) determined by Hydrophobic Interaction Chromatography (HIC). Finally, several approaches were evaluated to minimize the recovery loss. Capping the residual reactive groups on the ADC with maleimide containing reagents effectively mitigated the low recovery issue., (Copyright © 2016 Elsevier B.V. All rights reserved.)

The antibody-drug conjugate, trastuzumab emtansine (Kadcyla), is produced by attachment of the antitubulin drug, DM1, to lysine amines via a heterobifunctional linker, SMCC (succinimidyl 4-(N-maleimidomethyl)cyclohexane-1-carboxylate). Following the reaction of the N-hydroxysuccinimide activated linker with antibody lysines to produce a linker-modified intermediate (Tmab-MCC), DM1 is added to yield the desired product. In addition to the expected distribution of drug-linked forms (from 0 to 8), mass spectrometry also demonstrates the presence of a second distribution shifted by about +222 Da. This series is consistent with the presence of a population containing a bound linker without DM1 ("unconjugated linker"). Extended characterization of trastuzumab emtansine was performed using capillary isoelectic focusing, CE-SDS, peptide mapping, and LC/MS following (18)O labeling of peptide digests to identify this family of product variants. These studies demonstrate that the presence of these +222 Da species is due to an unexpected reaction of the maleimide moiety in the MCC linker with antibody lysine residues to produce cross-linked species that cannot conjugate to DM1.

A robust, high-throughput method using hydrophilic interaction liquid chromatography (HILIC) coupled with a charged aerosol detector (CAD) is reported as a novel approach for trisulfide quantitation in monoclonal antibodies (mAbs). The products of mAb reduction using tris(2-carboxyethyl)phosphine (TCEP) include a species (TCEP(S)) that is stoichiometrically produced from trisulfides. The TCEP reaction products are chromatographically separated, detected, and quantified by the HILICCAD method. The method was qualified to quantify trisulfides across a range of 1-40% (mol trisulfide/mol mAb). In all tested matrix components, assay linearity and intermediate precision were established with correlation coefficients (R(2))>0.99, and relative standard deviations (RSD)<10%. A method comparability study was performed using peptide mapping LC-MS as an orthogonal measurement. For the range of 1-40% trisulfides, the analysis demonstrates that, on average, HILICCAD reads between 0.95 and 1.10 times the value of LC-MS with 95% confidence. Applications of the HILICCAD method include trisulfide determination in purified mAbs to be used in the production of cysteine-linked antibody-drug conjugates, and in cell culture development studies to understand sources of, and strategies for control of, trisulfides., (Copyright © 2016 Elsevier B.V. All rights reserved.)

Rationale: The demographic, physiological, and computed tomography (CT) features associated with pneumothorax in smokers with and without chronic obstructive pulmonary disease (COPD) are not clearly defined., Objectives: We evaluated the hypothesis that pneumothorax in smokers is associated with male sex, tall and thin stature, airflow obstruction, and increased total and subpleural emphysema., Methods: The study included smokers with and without COPD from the COPDGene Study, with quantitative chest CT analysis. Pleural-based emphysema was assessed on the basis of local histogram measures of emphysema. Pneumothorax history was defined by subject self-report., Measurements and Main Results: Pneumothorax was reported in 286 (3.2%) of 9,062 participants. In all participants, risk of prior pneumothorax was significantly higher in men (odds ratio [OR], 1.55; 95% confidence interval [CI], 1.08-2.22) and non-Hispanic white subjects (OR, 1.90; 95% CI, 1.34-2.69). Risk of prior pneumothorax was associated with increased percent CT emphysema in all participants and participants with COPD (OR, 1.04 for each 1% increase in emphysema; 95% CI, 1.03-1.06). Increased pleural-based emphysema was independently associated with risk of past pneumothorax in all participants (OR, 1.05 for each 1% increase; 95% CI, 1.01-1.10). In smokers with normal spirometry, risk of past pneumothorax was associated with non-Hispanic white race and lifetime smoking intensity (OR, 1.20 for every 10 pack-years; 95% CI, 1.09-1.33)., Conclusions: Among smokers, pneumothorax is associated with male sex, non-Hispanic white race, and increased percentage of total and subpleural CT emphysema. Pneumothorax was not independently associated with height or lung function, even in participants with COPD. Clinical trial registered with www.clinicaltrials.gov (NCT00608764).

Trastuzumab emtansine (Kadcyla) is a recently approved antibody-drug conjugate produced by attachment of the anti-tubulin drug, DM1, to lysine amines via the SMCC linker. The resulting product exhibits a drug load distribution from 0 to 8 drugs per antibody that can be quantified using mass spectrometry. Different statistical models were tested against the experimental data derived from samples produced during process characterization studies to determine best fit. The Poisson distribution gives the best correlation for samples manufactured using the target process conditions (yielding the target average drug to antibody ratio (DAR) of 3.5) as well as those produced under conditions that exceed the allowed manufacturing ranges and yield products with average DAR values that are significantly different from the target (i.e., ≤3.0 or ≥4.0). The Poisson distribution establishes a link between average DAR values and drug load distributions, implying that measurement and control of the former (i.e., via a simple UV spectrophotometric method) could be used to indirectly control the latter in trastuzumab emtansine.

In an effort to characterise the whole transcriptome of the fungus Hypocrea jecorina, cDNA clones of this fungus were identified that encode for previously unknown proteins that are likely to function in biomass degradation. One of these newly identified proteins, found to be co-regulated with the major H. jecorina cellulases, is a protein that was denoted Cellulose induced protein 1 (Cip1). This protein consists of a glycoside hydrolase family 1 carbohydrate binding module connected via a linker region to a domain with yet unknown function. After cloning and expression of Cip1 in H. jecorina, the protein was purified and biochemically characterised with the aim of determining a potential enzymatic activity for the novel protein. No hydrolytic activity against any of the tested plant cell wall components was found. The proteolytic core domain of Cip1 was then crystallised, and the three-dimensional structure of this was determined to 1.5 Å resolution utilising sulphur single-wavelength anomalous dispersion phasing (sulphor-SAD). A calcium ion binding site was identified in a sequence conserved region of Cip1 and is also seen in other proteins with the same general fold as Cip1, such as many carbohydrate binding modules. The presence of this ion was found to have a structural role. The Cip1 structure was analysed and a structural homology search was performed to identify structurally related proteins. The two published structures with highest overall structural similarity to Cip1 found were two poly-lyases: CsGL, a glucuronan lyase from H. jecorina and vAL-1, an alginate lyase from the Chlorella virus. This indicates that Cip1 may be a lyase. However, initial trials did not detect significant lyase activity for Cip1. Cip1 is the first structure to be solved of the 23 currently known Cip1 sequential homologs (with a sequence identity cut-off of 25%), including both bacterial and fungal members.

Modern imaging methods like computed tomography (CT) generate 3-D volumes of image data. How do radiologists search through such images? Are certain strategies more efficient? Although there is a large literature devoted to understanding search in 2-D, relatively little is known about search in volumetric space. In recent years, with the ever-increasing popularity of volumetric medical imaging, this question has taken on increased importance as we try to understand, and ultimately reduce, errors in diagnostic radiology. In the current study, we asked 24 radiologists to search chest CTs for lung nodules that could indicate lung cancer. To search, radiologists scrolled up and down through a "stack" of 2-D chest CT "slices." At each moment, we tracked eye movements in the 2-D image plane and coregistered eye position with the current slice. We used these data to create a 3-D representation of the eye movements through the image volume. Radiologists tended to follow one of two dominant search strategies: "drilling" and "scanning." Drillers restrict eye movements to a small region of the lung while quickly scrolling through depth. Scanners move more slowly through depth and search an entire level of the lung before moving on to the next level in depth. Driller performance was superior to the scanners on a variety of metrics, including lung nodule detection rate, percentage of the lung covered, and the percentage of search errors where a nodule was never fixated.

Antibody-drug conjugates (ADCs) utilizing cysteine-directed linker chemistry have cytotoxic drugs covalently bound to native heavy-heavy and heavy-light interchain disulfide bonds. The manufacture of these ADCs involves a reduction step followed by a conjugation step. When tris(2-carboxyethyl)phosphine (TCEP) is used as the reductant, the reaction stoichiometry predicts that for each molecule of TCEP added, one interchain disulfide should be reduced, generating two free thiols for drug linkage. In practice, the amount of TCEP required to achieve the desired drug-to-antibody ratio often exceeds the predicted, and is variable for different lots of monoclonal antibody starting material. We have identified the cause of this variability to be inconsistent levels of interchain trisulfide bonds in the monoclonal antibody. We propose that TCEP reacts with each trisulfide bond to form a thiophosphine and a disulfide bond, yielding no net antibody free thiols for conjugation. Antibodies with higher levels of trisulfide bonds require a greater TCEP:antibody molar ratio to achieve the targeted drug-to-antibody ratio.

Purpose: Bedside chest radiography (CXR) represents a substantial fraction of the volume of medical imaging for inpatient health care facilities. However, its image quality is limited compared with posterior-anterior/lateral (PA/LAT) acquisitions taken in radiographic rooms. The aim of this study was to evaluate the utilization of bedside CXR and other chest imaging modalities before and after placing a radiography room within a thoracic surgical inpatient ward., Methods: All patient admissions (n = 3,852) to the thoracic surgical units between April 1, 2007, and December 31, 2010, were retrospectively identified. All chest imaging tests performed for these patients, including CT scans, MRI, ultrasound, and bedside and PA/LAT radiography, were counted. The primary outcome measure was chest imaging utilization, defined as the number of chest examinations per admission, before and after the establishment of the digital radiography room on January 10, 2010. Statistical analysis was performed using an independent-samples t test to evaluate changes in chest imaging utilization., Results: A 2.61-fold increase in the number of PA/LAT CXR studies per admission (P < .01) and a 1.96-fold decrease in the number of bedside CXR studies per admission (P < .01) were observed after radiography room implementation. The number of chest CT, MRI, and ultrasound studies per admission did not change significantly., Conclusions: Establishing a radiography room physically within thoracic surgery units or in close proximity can significantly shift CXR utilization from bedside to PA/LAT acquisitions, which may enable opportunities for improvement in efficiency, quality, and safety in patient care., (Copyright © 2012 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Castleman's disease (CD) is a rare benign lymphoid disorder with variable clinical course. The two principal histologic subtypes of CD are hyaline-vascular and plasma cell variants and the major clinicoradiological entities are unicentric and multicentric CD. Management of CD is tailored to clinicoradiologic subtype. In this review, we describe the CT, MR and PET/CT findings in Castleman's disease which can help suggest a diagnosis of CD as well as emphasize role of imaging in management of patients with CD., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

Rationale: Traditional genome-wide association studies (GWASs) of large cohorts of subjects with chronic obstructive pulmonary disease (COPD) have successfully identified novel candidate genes, but several other plausible loci do not meet strict criteria for genome-wide significance after correction for multiple testing., Objectives: The authors hypothesise that by applying unbiased weights derived from unique populations we can identify additional COPD susceptibility loci. Methods The authors performed a homozygosity haplotype analysis on a group of subjects with and without COPD to identify regions of conserved homozygosity haplotype (RCHHs). Weights were constructed based on the frequency of these RCHHs in case versus controls, and used to adjust the p values from a large collaborative GWAS of COPD., Results: The authors identified 2318 RCHHs, of which 576 were significantly (p<0.05) over-represented in cases. After applying the weights constructed from these regions to a collaborative GWAS of COPD, the authors identified two single nucleotide polymorphisms (SNPs) in a novel gene (fibroblast growth factor-7 (FGF7)) that gained genome-wide significance by the false discovery rate method. In a follow-up analysis, both SNPs (rs12591300 and rs4480740) were significantly associated with COPD in an independent population (combined p values of 7.9E-7 and 2.8E-6, respectively). In another independent population, increased lung tissue FGF7 expression was associated with worse measures of lung function., Conclusion: Weights constructed from a homozygosity haplotype analysis of an isolated population successfully identify novel genetic associations from a GWAS on a separate population. This method can be used to identify promising candidate genes that fail to meet strict correction for multiple testing.

Introduction: The possibility of expansion of pneumothorax (PTX) and/or pneumomediastinum (PMED) during commercial flights makes air travel after thoracic surgery particularly worrisome. Guidelines from the Aerospace Medical Association (AsMA) suggest delaying air travel 2 to 3 wk following uncomplicated thoracic surgery and 1 wk following radiographic resolution of PTX; they also state that PTX is an "absolute contraindication" to air travel. However, both AsMA guidelines and thoracic surgeons' recommendations for postoperative air travel require further examination., Methods: We reviewed the literature looking for evidence supporting official guidelines and conducted a survey of U.S. thoracic surgeons about their recommendations for air travel by patients with postoperative PTX and/or PMED., Results: We found no experimental evidence supporting the AsMA guidelines. Of the 68 thoracic surgeons who returned our questionnaire, 44% recommended that patients wait variable periods of time of up to 42 d (13.8 +/- 11.6 d) following complete resolution of PTX prior to air travel, while 46% of them allowed their patients to fly with some degree of PTX. Following mediastinoscopy, 76.9% of the surgeons allowed their patients to fly without delay, even with PMED. The only adverse in-flight event reported was a case of thoracic pain during ascent., Discussion: A wide variability exists among thoracic surgeons regarding their recommendations for air travel by patients with postoperative PTX and/or PMED. Both AsMA guidelines and surgeons' recommendations should rely more on scientific evidence. Studies of PTX and PMED expansion during simulated flight are needed to develop better guidelines.

THIOMABs are antibodies with an engineered unpaired cysteine residue on each heavy chain that can be used as intermediates to generate antibody-drug conjugates. Multiple charge variant peaks were observed during cation-exchange chromatography (CEX) and imaged capillary isoelectric focusing (cIEF) analysis of several different THIOMABs. This charge heterogeneity was due to cysteinylation and/or glutathionylation at the engineered and unpaired cysteines through disulfide bonds formed during the cell culture process. Cysteine treatment followed by analysis using CEX, LC/MS and electrophoresis demonstrates that cysteine is a mild reductant that can remove glutathione and cysteine bound to the engineered cysteines without disrupting the inter- or intra-chain disulfide bonds of antibodies. We further demonstrated that using a cysteine/cystine redox pair (rather than cysteine alone) can not only effectively remove glutathione at the engineered cysteines, but also generate homogeneously cysteinylated species, which resulted in one main peak in both CEX-HPLC and imaged cIEF assays for antibodies with engineered and unpaired cysteines.

Glossopharyngeal breathing, frequently performed by elite breath-hold divers, relies on muscles of the mouth and pharynx to move air into (glossopharyngeal insufflation, GI) and out of the lungs (glossopharyngeal exsufflation, GE). GI has also been used by patients with weak respiratory muscles. Fluoroscopic and endoscopic examinations were performed on four divers (three of whom were world record holders) during both GI and GE maneuvers. A detailed pictorial description of both GI and GE, with online video material that includes external, endoscopic and fluoroscopic examinations, is provided in this publication. Both GI and GE are accomplished with a coordinated series of contractions by glossopharyngeal muscles and they rely on a piston pump-like action of the larynx. In particular, the larynx moves extensively and repeatedly up and down, to either inject air into (GI) or extract it from the lungs (GE), with the vocal cords functioning as a valve. During both maneuvers, when the larynx is in its highest position, the epiglottis does not fold back, unlike what happens during swallowing.

CD22 represents a promising target for antibody-drug conjugate therapy in the context of B cell malignancies since it rapidly internalizes, importing specifically bound antibodies with it. To determine the pharmacokinetic parameters of anti-CD22-MCC-DM1 and MC-MMAF conjugates, various approaches to quantifying total and conjugated antibody were investigated. Although the total antibody assay formats gave similar results for both conjugates, the mouse pharmacokinetic profile for the anti-CD22-MCC-DM1 and MC-MMAF appeared significantly different depending on the conjugated antibody assay format. Since these differences significantly impacted the PK parameters determination, we investigated the effect of the drug/antibody ratio on the total and conjugated antibody quantification using multiple assay formats. Our investigations revealed the limitations of some assay formats to quantify anti-CD22-MCC-DM1 and MC-MMAF with different drug load and in the context of a heterogeneous ADC population highlight the need to carefully plan the assay strategy for the total and conjugated antibody quantification in order to accurately determine the ADC PK parameters.

The majority of researchers investigating hyperpolarized gas MRI as a candidate functional lung imaging modality have used (3)He as their imaging agent of choice rather than (129)Xe. This preference has been predominantly due to, (3)He providing stronger signals due to higher levels of polarization and higher gyromagnetic ratio, as well as its being easily available to more researchers due to availability of polarizers (USA) or ease of gas transport (Europe). Most researchers agree, however, that hyperpolarized (129)Xe will ultimately emerge as the imaging agent of choice due to its unlimited supply in nature and its falling cost. Our recent polarizer technology delivers vast improvements in hyperpolarized (129)Xe output. Using this polarizer, we have demonstrated the unique property of xenon to measure alveolar surface area noninvasively. In this article, we describe our human protocols and their safety, and our results for the measurement of the partial pressure of pulmonary oxygen (pO(2)) by observation of (129)Xe signal decay. We note that the measurement of pO(2) by observation of (129)Xe signal decay is more complex than that for (3)He because of an additional signal loss mechanism due to interphase diffusion of (129)Xe from alveolar gas spaces to septal tissue. This results in measurements of an equivalent pO(2) that accounts for both traditional T(1) decay from pO(2) and that from interphase diffusion. We also provide an update on new technological advancements that form the foundation for an improved compact design polarizer as well as improvements that provide another order-of-magnitude scale-up in xenon polarizer output.