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Abstract Objectives We aim to determine the prognostic significance of glutathione S‐transferase Pi 1 DNA methylation (mGSTP1) in two independent prostate cancer cohorts with long‐term clinical follow‐up data. Subjects/Patients and Methods We first re‐examined a published, in‐house whole genome bisulphite sequencing (WGBS) prostate cancer dataset, derived from radical prostatectomy (RP) tissue (n = 15) with median follow‐up 19.5 years, to confirm and visualise the association between mGSTP1 and patient mortality. To validate prognostic significance, we used a quantitative methylation‐specific head‐loop (MS‐HL) assay to measure mGSTP1 levels in a larger, independent cohort (n = 186), and performed univariable and multivariable Cox survival analysis. Results Re‐analysis of WGBS data showed a significant increase in mGSTP1 in RP samples from patients with lethal versus non‐lethal disease. Subsequent analysis in the larger cohort using the MS‐HL assay confirmed that mGSTP1 was detectable in 97% of RP samples, validating the diagnostic potential of mGSTP1. Univariable Cox survival analysis revealed a significant association between mGSTP1 levels and biochemical recurrence and metastatic relapse free survival, with a near‐significant association with prostate cancer specific mortality. Notably, multivariable Cox models demonstrated that mGSTP1 did not add independent prognostic value beyond standard clinicopathological features. Conclusion Our study supports the importance of DNA methylation as a tissue‐based prostate tumour biomarker. GSTP1 methylation is well established as a diagnostic marker, and in this study, we find that GSTP1 methylation levels are also associated with disease prognosis. Further research is required into the clinical utility of prognostic methylation markers and their functional role in disease progression.

Prostate adenocarcinoma is a common malignancy associated with a significant morbidity and mortality. In both prostate biopsies and radical prostatectomy specimens Gleason scoring informs both treatment and outcome prediction. The current convention is that in needle biopsies, Gleason patterns 3, 4 and 5 are considered to be malignant. Despite this there is debate as to whether or not Gleason score (GS) 3+3=6 should be diagnosed as cancer due to potential over-treatment and the psychological impact on patients. It is apparent that GS 3+3=6 is indolent disease with a low risk of metastasis. However, it does have the histological features of malignancy and is capable of infiltrating the prostate gland, extraprostatic extension, and metastatic spread. Furthermore GS 3+3=6 carcinoma has immunohistochemical and molecular genetic features similar to those of higher grade prostatic carcinoma. If GS 3+3=6 tumour is considered benign, the question arises should a benign label be given to the Gleason pattern 3 component of tumour that includes Gleason patterns of higher grade? This would seem a logical step as GS 3+3=6 cancers and the pattern 3 component in cancers with multiple patterns are morphologically identical. If pattern 3 is considered to be benign, then Gleason scoring would be limited to 4+4=8, 4+5=9, 5+4=9 and 5+5=10 which is clearly inappropriate. The correct strategy to address potential over-treatment of patients with low-grade cancer is clinician and patient education, not the recalibration of Gleason grading to reclassify malignant tumours as benign.

Abstract Background With the increasing availability of information, patients are becoming more informed about radiology procedures and requesting imaging studies. This qualitative study aims to explore factors that influence general practitioners' (GPs) decisions to fulfil patient requests for imaging studies during clinical consultation. Methods Semi‐structured interviews were conducted with 10 GPs working across five private medical centres in Northwest Sydney. Conventional content analysis was used with emergent themes to identify GPs perspectives. Results Six themes stood out from the interviews with GPs fulfilling patient requests for imaging studies. They included four pertaining to patient factors: patient expectations, ‘therapeutic scans’, ‘impressive labels’ and entitled. Two further themes pertained to the GP perspective and included defensive medicine, and ‘new patients’. Requests are fulfilled from anxious or health‐obsessed patients, with GPs worrying about litigation if they refuse. However, GPs decline requests from patients with entitlement attitudes or during first visits. Discussion The findings suggest that GPs struggle to balance their responsibilities as gatekeepers of imaging with patients' expectations of request fulfilment. Clear guidelines on the appropriate use of diagnostic imaging and its limitations could help patients understand its proper use and ease anxiety. Additionally, education and training for GPs could help them manage patient expectations and provide appropriate care. Patient Contributions Patients, service users, caregivers, people with lived experiences or members of the public were not directly involved in the design, conduct, analysis or interpretation of the study. However, our study was conducted in primary care facilities where the GPs were interviewed about patients' requests for diagnostic imaging based on their own initiatives. GPs' perspectives in managing patient expectations and healthcare utilisation were explored within the Australian Medicare system, where medical imaging and image‐guided procedures come at little to no cost to the individual. The study findings contribute to a better understanding of the challenges faced by GPs in dealing with patient consumerism and requests for diagnostic imaging, as well as factors influencing request fulfilment or denial. Insights gained from this study may inform future research about delivering patient‐centred care within a similar context.

Autophagy is the process by which damaged regions of the cytoplasm and intracellular pathogens are degraded. This mechanism often serves an adaptive role in cells, enhancing their survival. It plays a direct or indirect role in the development of various pathological conditions within the body. This phenomenon is common in various malignant diseases, where autophagy is associated with the resistance of transformed cells to chemotherapy. Conversely, abnormal activation of autophagy can trigger cell death, a process often seen in neurodegenerative conditions. Given that dysregulation of autophagy is associated with the progression of numerous pathological conditions, this is of significant interest to the developers of drugs that can effectively modulate autophagy for both basic research and clinical applications. Here, we provide a brief description of the mechanism of macroautophagy, the most prevalent form of autophagy identified in humans. We also discuss the clinical potential of drugs that can modulate autophagy, highlighting their use in combating diseases associated with direct or indirect dysregulation of this essential process.

Abstract Recently developed Long (≥100 cm) axial field of view (AFOV) PET/CT scanners are capable of producing images with higher signal‐to‐noise ratio, or performing faster whole‐body acquisitions, or scanning with lower radiation dose to the patient, compared with conventional PET/CT scanners. These benefits, which arise due to their substantially higher, by more than an order of magnitude, geometric efficiency, have been well described in the recent literature. The introduction of Long AFOV PET/CT technology into the clinic also has important implications for the design and workflow of PET/CT facilities and their effects on radiation exposure to staff and patients. Maximising the considerable benefits of this technology requires a thorough understanding of the relationships between these factors to optimise workflows while appropriately managing radiation exposure. This article reviews current knowledge on PET/CT facility design, workflows and their effects on radiation exposure, identifies gaps in the literature and discusses the challenges that need to be considered with the introduction of Long AFOV PET/CT into the clinic.

Abstract Current machine perfusion technology permits livers to be preserved ex situ for short periods to assess viability prior to transplant. Long-term normothermic perfusion of livers is an emerging field with tremendous potential for the assessment, recovery, and modification of organs. In this study, we aimed to develop a long-term model of ex situ perfusion including a surgical split and simultaneous perfusion of both partial organs. Human livers declined for transplantation were perfused using a red blood cell-based perfusate under normothermic conditions (36 °C) and then split and simultaneously perfused on separate machines. Ten human livers were split, resulting in 20 partial livers. The median ex situ viability was 125 h, and the median ex situ survival was 165 h. Long-term survival was demonstrated by lactate clearance, bile production, Factor-V production, and storage of adenosine triphosphate. Here, we report the long-term ex situ perfusion of human livers and demonstrate the ability to split and perfuse these organs using a standardised protocol.

Abstract Coral reef islands are amongst the most vulnerable environments to sea‐level rise (SLR). Recent physical and numerical modeling studies have demonstrated that overwash processes may enable reef islands to keep up with SLR through island accretion. Sediment supply to these islands from the surrounding reef system is critical in understanding their morphodynamic adjustments, but is poorly constrained due to insufficient knowledge about sediment delivery rates. This paper provides the first estimation of sediment delivery rates to coral reef islands. Analysis of topographic and geochronological data from 28 coral reef islands indicates an average rate of sediment delivery of c. 0.1 m3 m−1 yr−1, but with substantial inter‐island variability. Comparison with carbonate sediment production rates from census‐based studies suggests that this represents one quarter of the amount of sediment produced on the reef platform. Results of this study are useful in future modeling studies for predicting morphodynamic adjustments of coral reef islands to SLR.

IntroductionLiver cancers exhibit abnormal (leaky) vasculature, hypoxia and an immunosuppressive microenvironment. Normalization of tumor vasculature is an emerging approach to treat many cancers. Blockmir CD5-2 is a novel oligonucleotide-based inhibitor of the miR-27a interaction with VE-Cadherin, the endothelial-specific cadherin. The combination of a vasoactive medication with inhibition of immune checkpoints such as programmed cell death protein 1 (PD1) has been shown to be effective in treating liver cancer in humans. We aimed to study the effect of CD5-2 combined with checkpoint inhibition (using an antibody against PD1) on liver tumor growth, vasculature and immune infiltrate in the diethylnitrosamine (DEN)-induced liver tumor mouse model.MethodsWe first analyzed human miR-27a and VE-Cadherin expression data from The Cancer Genome Atlas for hepatocellular carcinoma. CD5-2 and/or anti-PD1 antibody were given to the DEN-treated mice from age 7-months until harvest at age 9-months. Tumor and non-tumor liver tissues were analyzed using histology, immunohistochemistry, immunofluorescence and scanning electron microscopy.ResultsHuman data showed high miR-27a and low VE-Cadherin were both significantly associated with poorer prognosis. Mice treated with CD5-2 plus anti-PD1 antibody had significantly smaller liver tumors (50% reduction) compared to mice treated with either agent alone, controls, or untreated mice. There was no difference in tumor number. Histologically, tumors in CD5-2-treated mice had less leaky vessels with higher VE-Cadherin expression and less tumor hypoxia compared to non-CD5-2-treated mice. Only tumors in the combination CD5-2 plus anti-PD1 antibody group exhibited a more favorable immune infiltrate (significantly higher CD3+ and CD8+ T cells and lower Ly6G+ neutrophils) compared to tumors from other groups.DiscussionCD5-2 normalized tumor vasculature and reduced hypoxia in DEN-induced liver tumors. CD5-2 plus anti-PD1 antibody reduced liver tumor size possibly by altering the immune infiltrate to a more immunosupportive one.

Measurement(s) Micrographs • Phase volume fractions • Two point correlations Technology Type(s) Material characterisation techniques (SEM, EBSD, light) • Computation

Abstract Background To inform effective genomic medicine strategies, it is important to examine current approaches and gaps in well-established applications. Lynch syndrome (LS) causes 3–5% of colorectal cancers (CRCs). While guidelines commonly recommend LS tumour testing of all CRC patients, implementation in health systems is known to be highly variable. To provide insights on the heterogeneity in practice and current bottlenecks in a high-income country with universal healthcare, we characterise the approaches and gaps in LS testing and referral in seven Australian hospitals across three states. Methods We obtained surgery, pathology, and genetics services data for 1,624 patients who underwent CRC resections from 01/01/2017 to 31/12/2018 in the included hospitals. Results Tumour testing approaches differed between hospitals, with 0–19% of patients missing mismatch repair deficiency test results (total 211/1,624 patients). Tumour tests to exclude somatic MLH1 loss were incomplete at five hospitals (42/187 patients). Of 74 patients with tumour tests completed appropriately and indicating high risk of LS, 36 (49%) were missing a record of referral to genetics services for diagnostic testing, with higher missingness for older patients (0% of patients aged ≤ 40 years, 76% of patients aged > 70 years). Of 38 patients with high-risk tumour test results and genetics services referral, diagnostic testing was carried out for 25 (89%) and identified a LS pathogenic/likely pathogenic variant for 11 patients (44% of 25; 0.7% of 1,624 patients). Conclusions Given the LS testing and referral gaps, further work is needed to identify strategies for successful integration of LS testing into clinical care, and provide a model for hereditary cancers and broader genomic medicine. Standardised reporting may help clinicians interpret tumour test results and initiate further actions.

Background: Major society guidelines recommend the fibrosis‐4 index (FIB‐4) as the initial step to risk stratifying people with metabolic dysfunction‐associated steatotic liver disease (MASLD). We aimed to evaluate the proportion of people with MASLD‐related hepatocellular carcinoma (HCC) and a low FIB‐4. Methods: This cohort study included 613 consecutive adults (33% female) diagnosed with MASLD‐related HCC from January 2008 to August 2023 at seven international centres in Australia, India, Japan, South Korea, Singapore and the United States. The primary objective was to determine the proportion of participants with a low FIB‐4, defined as FIB‐4 < 1.3, or < 2 if age > 65 years, in people without cirrhosis. Results: The mean (±SD) age and body mass index were 71 (±11) years and 27 (±7) kg/m2, respectively. Overall, 235 participants (38%) did not have known cirrhosis. The median FIB‐4 was 3.90 (IQR 2.42–6.42). A total of 78 participants (13%) had a low FIB‐4. Among participants without known cirrhosis (n = 235), 62 participants (26%) had a low FIB‐4. Participants with a low FIB‐4 had larger median total tumour diameter (p < 0.001) and lower median serum alpha‐fetoprotein (p = 0.005), compared to participants without a low FIB‐4. Cirrhosis was associated with lower odds of low FIB‐4, but not other factors such as male sex, type 2 diabetes, or obesity. Conclusion: More than a quarter of those with MASLD‐related HCC without cirrhosis have a low FIB‐4. The proposed clinical care pathways may not identify these people for further evaluation. [ABSTRACT FROM AUTHOR]

Introduction. Biliary complications are a common cause of morbidity after liver transplantation and associated with bile duct injury. To reduce injury, a bile duct flush is performed with high-viscosity preservation solution. It has been suggested that an earlier additional bile duct flush with low-viscosity preservation solution may reduce bile duct injury and biliary complications. This study aimed to investigate whether an earlier additional bile duct flush would reduce bile duct injury or biliary complications. Methods. A randomized trial was conducted using 64 liver grafts from brain dead donors. The control group received a bile duct flush with University of Wisconsin (UW) solution after donor hepatectomy. The intervention group received a bile duct flush using low-viscosity Marshall solution immediately after the onset of cold ischemia and a bile duct flush with University of Wisconsin solution after donor hepatectomy. The primary outcomes were the degree of histological bile duct injury, assessed using the bile duct injury score, and biliary complications within 24 mo of transplant. Results. Bile duct injury scores were not different between the 2 groups. Similar rates of biliary complications occurred in the intervention group (31% [n = 9]) and controls (23% [n = 8]) (P = 0.573). No difference between groups was observed for anastomotic strictures (24% versus 20%, P = 0.766) or nonanastomotic strictures (7% versus 6%, P = 1.00). Conclusions. This is the first randomized trial to investigate an additional bile duct flush using low-viscosity preservation solution during organ procurement. The findings from this study suggest that performing an earlier additional bile duct flush with Marshall solution does not prevent biliary complications and bile duct injury.

Introduction. Histopathological assessment of liver biopsies is the current “gold standard” for diagnosing graft dysfunction after liver transplantation (LT), as graft dysfunction can have nonspecific clinical presentations and inconsistent patterns of liver biochemical dysfunction. Most commonly, post-LT, graft dysfunction within the first year, is due to acute T-cell mediated rejection (TCMR) which is characterised histologically by the degree of portal inflammation (PI), bile duct damage (BDD), and venous endothelial inflammation (VEI). This study aimed to establish the relationship between global assessment, which is the global grading of rejection using a “gestalt” approach, and the rejection activity index (RAI) of each component of TCMR as described in revised Banff 2016 guidelines. Methods. Liver biopsies (n = 90) taken from patients who underwent LT in 2015 and 2016 at the Australian National Liver Transplant Unit were identified from the electronic medical records. All biopsy slides were microscopically graded by at least two assessors independently using the revised 2016 Banff criteria. Data were analysed using IBM SPSS v21. A Fisher–Freeman–Halton test was performed to assess the correlation between the global assessment and the RAI scores for each TCMR biopsy. Results. Within the cohort, 60 (37%, n = 164) patients underwent at least 1 biopsy within 12 months after LT. The most common biopsy outcome (total n = 90) was acute TCMR (64, 71.1%). Global assessment of TCMR slides strongly positively correlated with PI (p value

BackgroundVessels that encapsulate tumor clusters (VETC) is a novel vascular pattern seen on hepatocellular carcinoma (HCC) histology which has been shown to independently predict tumor recurrence and survival after liver resection. Its prognostic value in HCC patients receiving liver transplantation (LT) is unclear.MethodsWe retrospectively studied consecutive adults who underwent deceased-donor LT with active HCC found on explant between 2010-2019. Tumor tissue was stained for CD34 and quantified for VETC. Primary and secondary endpoints were time to recurrence (TTR) and recurrence-free survival (RFS).ResultsDuring the study period, 158 patients received LT where HCC was present on explant. VETC pattern was seen in 76.5% of explants. Patients with VETC-positive tumors spent longer on the waitlist (6.4 vs. 4.1 months, P=0.048), had higher median tumor numbers (2 vs. 1, P=0.001) and larger tumor sizes (20mm vs. 13mm, P

Abstract Background Prostate cancer is a clinically heterogeneous disease with a subset of patients rapidly progressing to lethal‐metastatic prostate cancer. Current clinicopathological measures are imperfect predictors of disease progression. Epigenetic changes are amongst the earliest molecular changes in tumourigenesis. To find new prognostic biomarkers to enable earlier intervention and improved outcomes, we performed methylome sequencing of DNA from patients with localised prostate cancer and long‐term clinical follow‐up. Methods We used whole‐genome bisulphite sequencing (WGBS) to comprehensively map and compare DNA methylation of radical prostatectomy tissue between patients with lethal disease (n = 7) and non‐lethal (n = 8) disease (median follow‐up 19.5 years). Validation of differentially methylated regions (DMRs) was performed in an independent cohort (n = 185, median follow‐up 15 years) using targeted multiplex bisulphite sequencing of candidate regions. Survival was assessed via univariable and multivariable analyses including clinicopathological measures (log‐rank and Cox regression models). Results WGBS data analysis identified cancer‐specific methylation patterns including CpG island hypermethylation, and hypomethylation of repetitive elements, with increasing disease risk. We identified 1420 DMRs associated with prostate cancer‐specific mortality (PCSM), which showed enrichment for gene sets downregulated in prostate cancer and de novo methylated in cancer. Through comparison with public prostate cancer datasets, we refined the DMRs to develop an 18‐gene prognostic panel. Applying this panel to an independent cohort, we found significant associations between PCSM and hypermethylation at EPHB3, PARP6, TBX1, MARCH6 and a regulatory element within CACNA2D4. Strikingly in a multivariable model, inclusion of CACNA2D4 methylation was a better predictor of PCSM versus grade alone (Harrell's C‐index: 0.779 vs. 0.684). Conclusions Our study provides detailed methylome maps of non‐lethal and lethal prostate cancer and identifies novel genic regions that distinguish these patient groups. Inclusion of our DNA methylation biomarkers with existing clinicopathological measures improves prognostic models of prostate cancer mortality, and holds promise for clinical application.