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Recent studies on recombinant adeno‐associated viral (rAAV) vector production demonstrated the generation of infectious viral particles in Saccharomyces cerevisiae. Proof‐of‐concept results showed low vector yields that correlated with low AAV DNA encapsidation rates. In an attempt to understand the host cell response to rAAV production, we profiled proteomic changes throughout the fermentation process by mass spectrometry. By comparing an rAAV‐producing yeast strain with a respective non‐producer control, we identified a subset of yeast host proteins with significantly different expression patterns during the rAAV induction period. Gene ontology enrichment and network interaction analyses identified changes in expression patterns associated mainly with protein folding, as well as amino acid metabolism, gluconeogenesis, and stress response. Specific fold change patterns of heat shock proteins and other stress protein markers suggested the occurrence of a cytosolic unfolded protein response during rAAV protein expression. Also, a correlative increase in proteins involved in response to oxidative stress suggested cellular activities to ameliorate the effects of reactive oxygen species or other oxidants. We tested the functional relevance of the identified host proteins by overexpressing selected protein leads using low‐ and high‐copy number plasmids. Increased vector yields up to threefold were observed in clones where proteins SSA1, SSE1, SSE2, CCP1, GTT1, and RVB2 were overexpressed. Recombinant expression of SSA1 and YDJ insect homologues (HSP40 and HSC70, respectively) in Sf9 cells led to a volumetric vector yield increase of 50% relative to control, which validated the importance of chaperone proteins in rAAV‐producing systems. Overall, these results highlight the utility of proteomic‐based tools for the understanding and optimization of rAAV‐producing recombinant strains., Proteomic changes in yeast recombinant and control strains were profiled to identify cellular events associated with adeno‐associated viral (AAV) vector production. Bioinformatics data analysis suggested cytoplasmic unfolded protein response was primarily taking place in the AAV‐producing yeast strain. Additional changes related to response to stress and amino acid and glucose metabolism were identified. Host protein overexpression was hypothesized as a means for molecular optimization. Overexpression of SSA1, YDJ, SSE1, and other selected proteins in AAV‐producing yeast strains and insect cells resulted in increased vector yield.

While the prognosis of patients with locoregional esophageal adenocarcinoma (EAC) has improved in the neoadjuvant treatment (NAT) era, high-grade histology (G3) is still associated with a limited treatment response. We sought to investigate oncologic outcomes in patients after esophagectomy for G3 EAC and to identify predictors of poor survival among these patients.Patients with EAC who underwent resection with curative intent in 2011-2018 were divided by histologic grade (G3, G1/2) and compared for overall survival (OS). Cox regression was performed to analyze the response to NAT and the predictive role of signet ring cell (SRC) features.The cohort included 163 patients, 94 (57.7%) with G3 histology. NAT was administered to 69 (73.4%) patients. Following resection, OS in the G3 EAC group was 30 months (95% confidence interval [CI] 23.9-36.1). On univariate analysis, G3 disease (p = 0.050) and SRC features (p = 0.019) predicted low OS. Median survival in the G3 EAC group was worse in patients with SRC histology (18 months, 95% CI 8.6-27.4) than those without (30 months, 95% CI 23.8-36.1; p = 0.041). No patients with SRC histology were alive at 5 years of follow-up. Among all patients administered NAT, 88.2% of those with SRC showed minimal or no pathologic response and only 27.8% were downstaged.High-grade histology was found in most patients with EAC and predicted poor survival and treatment response. SRC features in patients with G3 disease were associated with lower OS. The benefit of NAT for G3 EAC in patients with SRC histology appears limited.

Adeno associated virus (AAV) capsids are a leading modality for in vivo gene delivery. Complete and precise characterization of capsid particles, including capsid and vector genome concentration, is necessary to safely and efficaciously dose patients. Size exclusion chromatography (SEC) coupled to multiangle light scattering (MALS) offers a straightforward approach to comprehensively characterize AAV capsids. The current study demonstrates that this method provides detailed AAV characterization information, including but not limited to aggregation profile, size-distribution, capsid content, capsid molar mass, encapsidated DNA molar mass, and total capsid and vector genome titer. Currently, multiple techniques are required to generate this information, with varying accuracy and precision. In the current study, a new series of equations for SEC-MALS are used in tandem with intrinsic properties of the capsids and encapsidated DNA to quantify multiple physical AAV attributes in one 20-min run with minimal sample manipulation, high accuracy, and high precision. These novel applications designate this well-established method as a powerful tool for product development and process analytics in future gene therapy programs.

Background Research is limited on combining outpatient parenteral antimicrobial therapy (OPAT) with addiction treatment for people who inject drugs (PWID) with serious infections. Methods This is a retrospective study of PWID (n = 68) requiring intravenous antibiotics evaluated for suitability for our OPAT program with concurrent addiction treatment. Results Most common infections were bacteremia and/or endocarditis (73.5%), bone and/or joint infections (32.4%), and epidural abscess (22.1%). Of the 20 patients (29.4%) who qualified, 100.0% completed the course of antibiotics, 30.0% experienced a 30-day readmission, and 15.0% relapsed. No overdoses, deaths, or peripherally inserted central catheter-line complications were reported. Conclusions Outpatient parenteral antimicrobial therapy with addiction treatment may be feasible and safe for PWID with serious infections.

Current management guidelines recognize the impact of hepatic versus peritoneal sided gallbladder cancers (GBC) on survival. However, no data exist regarding the significance of anatomic tumor location within the gallbladder.We retrospectively analyzed all GBC that underwent surgical resection with curative intent in our health system from 2007 to 2017. We evaluated the effect of anatomic pathologic tumor location (fundus/body, neck, and multifocal) on clinicopathologic, perioperative, and oncologic outcomes.About 97 patients met criteria; 63% fundus/body, 22% multifocal, and 15% neck. Compared with fundus/body, neck tumors more frequently presented with preoperative jaundice (53% vs. 13%, p .001), were smaller (20 mm vs. 30 mm, p = .068) and had significantly more biliary tree invasion (33% vs. 13%, p = .030) on histopathology. Although tumor characteristics (pTNM stage, liver invasion, lymphovascular invasion, prognostic nutritional index, and grade) were similar, neck tumors had significantly higher rates of R0 resection (53% vs. 11%, p .001). Rates of adjuvant therapy were similar. Median PFS was similar between cohorts (p = .356). However, median overall survival (OS) was significantly shorter in neck (21 months) than fundus/body tumors (NR 109 months), p = .015.Neck tumors were rare, small and more likely to result in jaundice secondary to biliary tree invasion. Despite higher R0 resection rates, these tumors had significantly worse OS.

Background: There are numerous non-biologic and biologic disease modifying anti-rheumatic drugs (bDMARDs) for rheumatoid arthritis (RA). Typical sequences of bDMARDs are not clear. Future treatment policies and trials should be informed by quantitative estimates of current treatment practice. Methods: We used data from Corrona, a large real-world RA registry, to develop a method for quantifying sequential patterns in treatment with bDMARDs. As a proof of concept, we study patients who eventually use tocilizumab monotherapy (TCZm), an IL-6 antagonist with similar benefits used as monotherapy or in combination. Patients starting a bDMARD were included and were followed using a discrete-state Markov model, observing changes in treatments every six-months and determining whether they used TCZm. A supervised machine learning algorithm was then employed to determine longitudinal patient factors associated with TCZm use.Results: 7,300 patients starting a bDMARD were followed for up to 5 years. Their median age was 58 years, 78% were female, median disease duration was 5 years, and 57% were seropositive. During follow-up, 287 (3.9%) reported use of TCZm with median time until use of 25.6 (11.5, 56.0) months. 82% of TCZm use began within three years of starting any bDMARD. 93% of TCZm users switched from TCZ combination, a TNF inhibitor, or another bDMARD. Very few patients are given TCZm as their first DMARD (0.6%). Variables associated with use of TCZm included: prior use of TCZ combination therapy, older age, longer disease duration, seronegative, higher disease activity, and no prior use of a TNF inhibitor.Conclusions: Improved understanding of treatment sequences in RA may help personalize care. These methods may help optimize treatment decisions using large-scale real-world data.

Background Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) is effective in select patients with peritoneal metastases of colorectal (CRC) origin. The impact of different biomarkers in predicting recurrence after CRS/HIPEC is unclear. Methods Retrospective review of patients who underwent CRS/HIPEC for PC of CRC origin from 03/2007–08/2017. Molecular profile of the primary tumor was obtained from pathology reports, whenever available. Results Overall, 100 patients underwent CRS/HIPEC for peritoneal metastases of CRC origin. Most patients presented high grade tumor histology (G2/G3, n = 97, 97%), and a majority showed mucinous features (n = 61, 61%). At a median follow-up of 18 months, median DFS for the overall population was 13 months (95% CI 9.6, 16.4). Data reporting at least one mutational analysis was available in 64 patients. Microsatellite stability was detected in 42/50 (84%) patients, mKRAS in 25/51 (49%), and mBRAF in 5/35 (14.3%). On Kaplan–Meier analysis, BRAF was the only mutation associated with poor DFS (16 months, CI 95% 11.7–43.3 vs. 7 months, CI 95% 2.1–11.9, p = .008). On multivariate analysis, mBRAF independently predicted earlier recurrence (p = .032). Conclusions In this analysis, mBRAF was independently associated with earlier recurrence in patients undergoing CRS/HIPEC for CRC, leading to dismal median DFS (7 months). Strict patient selection is advisable in these patients.

Digital workplace has become an integral part of the modern world (Thomas, 2011). Employees are communicating and collaborating digitally in unprecedented ways, where people are working remote without having handshake and/or a face to face experience one another (Suri, 2019). In such work environments, purpose oriented team development is an archetypal ingredient in the formation of strong team destined to success (Gregory, 2018). This article closely examines Tuckman’s model of team formation and tries to stress the relevance of the model in building a focused kind of digital team in the digital world. To this end, the study emphases on descriptive analysis of the information gathered from secondary data sources, along with primary data obtained thru questionnaire and interviews from IT professionals engaged in digital teams. The finding exhibits that Tuckman's model can have a significant contribution in an attempt to build a purpose oriented digital team in the IT industry, and by so doing enhance precision, innovation, and aptitude while adding upon the quality of the product.

Ethiopia, a country once denoted as the cradle of mankind with a civilization of over 3000 years (Williams, 1997), is now at the threshold of disintegration (Leta, 199). Since the prejudiced exclusionary tribal political ideology, which was authored and delivered by TPLF (Tigray Liberation Front), has come to the show in 1991 (Hagman, 2013), the country has jolted into recurrent political turmoil and instability (Abbink, 2011). Following this, the passion and agility of citizens to digital trade has been distressed, paving the way to the threat of a potential digital divide. This article examines the impact of the practice of this political ideology on public passion for digital trade, and if this impact leads to the prevalence of digital divide in the country. To this end, a comprehensive analysis is made on the data gathered thru a questionnaire from a sample size that contains 45 informants. GPower and SPSS have been used to determine the sample size population and analyze the data gathered therefrom. The finding exhibits that the xenophobic tribal political ideology has a significant impact the craving public passion to digital trade, signifying the imminent of the manifestation of digital divide.

INTRODUCTION Cross-sectional data of pediatric blunt solid organ injury demonstrates higher rates of nonoperative management and shorter lengths of stay (LOSs) in pediatric trauma centers (PTCs) versus adult trauma centers (ATCs) or dual trauma centers (DTCs). Recent iterations of guidelines (McVay 2008, J Pediatr Surg 2008;43(6):1072-1076 J Trauma Acute Care Surg 2015;79(4):683-693) have emphasized physiologic parameters rather than injury grade in clinical decision making, improving resource allocation and decreasing LOS. We sought to evaluate how these guidelines have influenced care. METHODS The National Trauma Data Bank (2007-2016) was queried for isolated spleen and liver injuries in patients younger than 19 years. Linear regression, odds ratio (OR), and χ test were used to determine significance between operative intervention or LOS among different trauma center types and grade of injury. RESULT A total of 55,036 blunt spleen or liver injuries were identified. Although operative rates decreased in ATCs over time (p = 0.037), patients treated at ATCs or DTCs continued to demonstrate higher ORs of operative intervention (OR, 4.43 and 2.88, respectively) compared with PTCs. Mean LOS decreased by 1.52 (p < 0.001), 0.49 (p = 0.26), and 1.31 (p = 0.05) days at ATC, DTC, and PTC to 6.43, 6.68, and 5.16 days. Improvement in LOS for ATCs was distributed across injury Grades I, II, and IV, while there was no correlation among PTCs for injury grade. CONCLUSION Despite more than a decade of guidelines in pediatric solid organ injury supporting nonoperative management and accelerated discharge pathways based on physiologic parameters, rates of operative intervention remain much higher in ATCs versus PTCs, and all centers appear to fall short of consensus guidelines for discharge. LEVEL OF EVIDENCE Care management study, level IV.

Twenty-six samples (n = 24 spp.) of foods eaten, including ferns, shrubs, vines, orchids, herbaceous plants, and tree leaves, were collected from the Yopno, Uruwa, and Som Conservation Area at approximately 1,800 m altitude on the Huon Peninsula, Papua New Guinea (PNG). Samples were weighed fresh in the field and transported to the Lae National Herbarium in PNG for drying and confirmed identification, before transporting to the US for analysis of primary nutrient composition and minerals. Water content averaged 76 ± 10% (mean ± standard deviation); on a dry matter (DM) basis, foods averaged moderate protein (11 ± 5%), and soluble carbohydrate (27 ± 8%) content, along with exceptionally low starch (1 ± 1%) and crude fat (3 ± 2%) values, and moderate to high values in fiber fractions (neutral detergent fiber 52 ± 13%, acid detergent fiber 39 ± 10%, lignin 15 ± 6%). Calculated metabolizable energy content of native forages averaged 1.9 ± 0.3 Mcal/kg DM (ruminant model). Macromineral concentrations (DM basis) were not exceptional (calcium 1.1 ± 1.0%, phosphorus 0.2 ± 0.1%, magnesium 0.3 ± 0.2%, potassium 1.8 ± 0.9%, sodium 0.02 ± 0.02%), and select trace minerals were within anticipated ranges for herbivores (copper 12 ± 13 mg/kg, iron 48 ± 26 mg/kg, zinc 34 ± 18 mg/kg) with the exception of manganese (268 ± 225 mg/kg), which could be considered on the high end of dietary adequacy for most herbivores. These data provide useful information that can be used to adjust nutrient targets for dietary development and feeding management of captive populations of tree kangaroos.

Background and objectives The impact of medications for opioid use disorder (MOUD) on against medical advice (AMA) discharges among people who inject drugs (PWID) hospitalized for endocarditis is unknown. Methods A retrospective review of all PWID hospitalized for endocarditis at our institution between 2016 and 2018 (n = 84). Results PWID engaged with MOUD at admission, compared with those who were not, were less likely to be discharged AMA but this did not reach statistical significance in adjusted analysis (odds ratio [OR], 0.22; 95% confidence interval [CI], 0.033-1.41; P = .11). Among out-of-treatment individuals, newly initiating MOUD did not lead to significantly fewer AMA discharges (OR, 0.98; 95% CI, 0.26-3.7; P = .98). Conclusion and scientific significance PWID hospitalized for endocarditis are at high risk for discharge AMA but more research is needed to understand the impact of MOUD. (Am J Addict 2020;29:155-159).

This report describes patterns of disease recurrence after optimal cytoreduction (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal carcinomatosis (PC) of colorectal (CRC) and appendiceal adenocarcinoma (AC) origin. Patients undergoing optimal CRS/HIPEC (2007–2016) at the authors’ institution were retrospectively reviewed from a prospectively maintained database. Data regarding disease recurrence were analyzed. Of 74 patients who underwent CRS/HIPEC for PC from CRC (n = 46) or AC (n = 28), 49 (66%) had recurrence during a median follow-up period of 39.5 months. The sites of recurrence were peritoneal-only (n = 34, 69%), hematogenous-only (n = 6, 12%), and combined peritoneal and hematogenous (n = 9, 19%) sites. No patients with AC had hematogenous-only recurrence. The median disease-free survival (DFS) time for all the patients was 15 months (95% confidence interval [CI] 12.5–17.5 months). The recurrence rate after CRS/HIPEC was 41% at 1 year, 73% at 3 years, and 76% at 5 years. All the patients with hematogenous-only metastases experienced recurrence within 12 months after CRS/HIPEC. Mucinous or signet ring features predicted peritoneal recurrence (p = 0.041), whereas a complete cytoreduction of 1 was a predictor of early recurrence (p = 0.040). Patients who underwent repeat cytoreduction survived longer than those who received systemic chemotherapy alone. The median survival time after peritoneal-only recurrence was 33 months (95% CI 27.8–38.9 months). Recurrence for patients with PC is common, even after optimal CRS/HIPEC. Hematogenous-only recurrence occurs early after CRS/HIPEC, suggesting occult disease at the time of treatment and highlighting the need for methods to identify micro-metastases and improve patient selection. Patients experiencing peritoneal-only recurrence had long survival period after CRS/HIPEC, suggesting its effectiveness at controlling peritoneal disease for a time.

Background. Gonadotropin-releasing hormone (GnRH) agonists are FDA approved for the treatment of precocious puberty. The therapy consists of histrelin acetate (Supprelin), a surgically implanted device, or Lupron injections. In recent years, the use of these agents has been extended to include the off-label treatment of children with normally timed puberty. Trends in the off-label use of GnRH agonists in children across the U.S. have not been previously described in the literature. Methods. We analyzed data on the use of Supprelin and Lupron reported to the Pediatric Health Information System (PHIS) from 2013 to 2016 to determine the trends in both the FDA–approved and off-label uses of these medications. Results. We identified a stable cohort of 39 children’s hospitals administering GnRH agonist therapies from 2013 to 2016. During this period, the annual number of children treated with these medications for precocious puberty increased modestly, from 283 to 303; meanwhile, the fraction of children receiving therapy for an off-label indication more than doubled, from 12% (39 of 322 total patients) to 29% (125 of 428 total patients). Privately insured patients were more likely to be treated for an off-label indication (13%; 119 out of 883 patients) than Medicaid patients (8%; 58 out of 706 patients; χ2[1] = 10.97, P = .00093). Conclusion. From 2013 to 2016, the proportion of children treated with GnRH agonists for an off-label indication notably increased. The number of children treated for precocious puberty modestly increased. Private insurance coverage was associated with higher rates of off-label use.

Background: The objective of the study was to identify national trends in the utilization of histrelin acetate implants among transgender children in the United States. Methods: We analyzed demographic, diagnostic and treatment data from 2004 to 2016 on the use of histrelin acetate reported to the Pediatric Health Information System (PHIS) to determine the temporal trends in its use for transgender-related billing diagnoses, e.g. “gender identity disorder”. Demographic and payer status data on this patient population were also collected. Results: Between 2004 and 2016, the annual number of implants placed for a transgender-related diagnosis increased from 0 to 63. The average age for placement was 14 years. Compared to natal females, natal males were more likely to receive implants (57 vs. 46) and more likely to have implants placed at an older age (62% of natal males vs. 50% of natal females were ≥;13 years; p Conclusions: Utilization of histrelin acetate implants among transgender children has increased dramatically. Compared to natal females, natal males are more likely to receive implants and also more likely to receive implants at an older age. Treated transgender patients are more likely to be White when compared to the larger cohort of patients being treated with histrelin acetate for central precocious puberty (CPP), thus identifying a potential racial disparity in access to medically appropriate transgender care.

Feeding intolerance, poor oral feeding skills, and retching are common symptoms seen in medically complex infants with a history of abdominal disorders and surgical interventions, such as gastrostomy tube placement and Nissen fundoplication. Visceral hyperalgesia may play a role in the underlying pathophysiology. We report the use of orally administered gabapentin in 3 infants with presumed visceral hyperalgesia presenting as poor tolerance of enteral and oral feeds. Retching and outward discomfort associated with feeds was resolved within 2 to 3 days of initiation of therapy. Full oral feeds were obtained in all 3 patients within 3 to 4 months of starting gabapentin without changing adjunctive medications or therapies. After attainment of full oral feeds, all patients were successfully weaned off gabapentin over a month, with no notable side effects, signs of withdrawal, or impact on ability to feed by mouth.

Background Polycystic Ovarian Syndrome (PCOS) and Pilonidal Disease (PD) have been associated with a number of dermatologic conditions such as hirsutism, acne, seborrheic dermatitis, androgenetic alopecia, psoriasis and hidradenitis suppurativa. These conditions share similar risk factors including obesity, elevated androgens and metabolic syndrome. There is scant evidence about association between PCOS and PD. Prevalence of PD in adolescents is 0.7% and of PCOS is 8 to 13%. Pilonidal disease and PCOS are associated with significant morbidity and decreased quality of life, thus early diagnosis and treatment are important. We sought to determine whether pilonidal disease is associated with PCOS and whether severity of PD is greater in patients with concurrent PCOS and whether treatment of PCOS reduces pilonidal disease severity. Methods This was a retrospective chart review approved by the Institutional Review Board. Inclusion criteria was all girls aged 12 to 21 receiving a diagnosis of PCOS or PD from 2012-2019 at a tertiary medical center. Variables analyzed included age, race/ethnicity, BMI, menarche, tobacco use, payer status, treatment of PCOS and PD, serum markers of hyperandrogenism and metabolic syndrome. Data was analyzed with Student's t-test, chi-squared test, and multiple logistic regression Results In total, 100, 043 patients presented to an urban tertiary medical center with 769 patients diagnosed with PD of which 209 patients were diagnosed with both PD and PCOS. Patients with both diagnoses were more likely to have a higher BMI (31.4 v. 27.4, p Conclusions There is a higher prevalence of PCOS among adolescent girls diagnosed with PD. PCOS treatment appears to confer a protective effect in reducing risk of intervention for PD. Increased awareness of the association between PCOS and PD among providers taking care of female adolescents with PD should result in lower threshold for screening for PCOS and/or referral to adolescent gynecology for further evaluation. If future studies involving diverse population show replicability of these findings, formalized practice guidelines aimed at screening for PCOS in girls presenting with PD should be developed. This approach may improve early detection and ultimately treatment of PCOS.

Cancer research relies on a plethora of disease-relevant tumor models, but patient specific models are still being developed. In this study, we show the utility of patient-specific pancreatic, ovarian and breast cancer models in the context of the metastatic niche, composed of co-cultured mesenchymal stem cells (MSC) in three-dimensional tumor spheroids. Additionally, different ratios of MSC's were seeded with the cancer spheroids to interrogate the effect of MSC's on chemotherapeutic drug response in defined media conditions. The patient-specific and treatment-naive cancer models represent a diverse range of disease type, progression grade, and genetic profiles. These models were co-cultured with MSC's sourced from both bone marrow and adipose tissue. These co-culture models were tested with a panel of common, broad-range chemotherapeutic agents as well as several disease-specific drugs. The resulting drug responses show that the presence of MSC's within the context of the metastatic niche causes attenuation towards a higher chemotherapeutic drug resistance. The tumor models exhibit a varied chemotherapeutic response when MSC's are seeded in 50:1, 5:1, or 1:1 ratio with cancer cells, suggesting that even a small presence of MSC's may have a significant effect on the drug resistance of metastatic tumor spheroids. While this MSC-induced drug response attenuation is observed across the broad spectrum of patient profiles and disease types, the strength of the effect is not homogenous. The observed variability in the strength of the effect was impacted by the disease type of the cancer cells, the source of the MSC's, and the specific drug used in the metastatic tumor model. We propose that using these reproducible and easily scaled models of metastatic tumors to find effective chemotherapeutic drugs could increase our understanding of the tumor microenvironment, the onset of metastasis, and the process of cancer grafting into other tissues. Discovering effective and targeted therapies utilizing a more advanced model of the metastatic tumor niche could increase the success rate of an eventual clinical trial. Citation Format: Liam Deems, Amit Shahar, Amy Pepicelli, Cheryl Murphy, Daniel Solomon, David Deems, Dmitry Shvartsman. Modeling the metastatic niche interactions between patient tumor and mesenchymal cells to identify drivers of chemotherapy drug resistance [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 3164.

Recombinant adeno-associated virus (rAAV) vectors are increasingly popular tools for gene therapy applications. Their non-pathogenic status, low inflammatory potential, availability of viral serotypes with different tissue tropisms, and prospective long-lasting gene expression are important attributes that make rAAVs safe and efficient therapeutic options. Over the last three decades, several groups have engineered recombinant AAV-producing platforms, yielding high titers of transducing vector particles. Current specific productivity yields from different platforms range from 103 to 105 vector genomes (vg) per cell, and there is an ongoing effort to improve vector yields in order to satisfy high product demands required for clinical trials and future commercialization. Crucial aspects of vector production include the molecular design of the rAAV-producing host cell line along with the design of AAV genes, promoters, and regulatory elements. Appropriately, configuring and balancing the expression of these elements not only contributes toward high productivity, it also improves process robustness and product quality. In this mini-review, the rational design of rAAV-producing expression systems is discussed, with special attention to molecular strategies that contribute to high-yielding, biomanufacturing-amenable rAAV production processes. Details on molecular optimization from four rAAV expression systems are covered: adenovirus, herpesvirus, and baculovirus complementation systems, as well as a recently explored yeast expression system.

We establish the existence of an open set of initial conditions through which pass solutions without singularities to Newton's gravitational equations in R 3 on a semi-infinite interval in forward time, for which every pair of particles separates like A t , A > 0 , as t → ∞ . The solutions are constructable as series with rapid uniform convergence and their asymptotic behavior to any order is prescribed. We show that this family of solutions depends on 6N parameters subject to certain constraints.

Older age is an independent predictor of worse outcome from traumatic brain injury (TBI). No clear guidelines exist for the management of TBI in elderly patients.To describe the outcomes of elderly patients presenting with TBI and intracranial bleeding (ICB), comparing a very elderly population (≥ 80 years of age) to a younger one (70-79).Retrospective analysis of the outcomes of elderly patients presenting with TBI with ICB admitted to a level I trauma center.The authors analyzed 100 consecutive patients aged 70-79 and 100 patients aged 80 and older. In-hospital mortality rates were 9% and 21% for groups 70-79 and ≥ 80 years old, respectively (P = 0.017). Patients 70-79 years old showed a 12-month survival rate of 73% and a median survival of 47 months. In patients ≥ 80 years old, 12-month survival was 63% and median survival was 27 months (P = NS). In patients presenting with a Glasgow Coma Scale score of ≥ 8, the in-hospital mortality rates were 41% (n=5/12) and 100% (n=8/8). Among patients ≥ 80 years old undergoing emergent surgical decompression, in-hospital mortality was 66% (n=12/18). Survivors presented with a severe drop in their functional score. Survival was dismal in patients ≥ 80 years old who were treated conservatively despite recommended operative guidelines.There is a lack of reliable means to evaluate the outcome in patients with poor functional status at baseline. The negative prognostic impact of severe TBI is profound, regardless of treatment choices.

Treatment approaches for pediatric papillary thyroid cancer (PTC) are historically extrapolated from adult experience. However, pediatric PTC demonstrates a greater propensity for lymph node involvement, early metastases, and recurrence, highlighting the need for pediatric-specific treatment paradigms.A retrospective review included patients with PTC aged ≤21 y, with ≥18 mo of follow-up, treated between 2002 and 2015. Fisher's exact test and Cox proportional hazard were used to estimate the effect of risk factors on disease recurrence.Seventy-two cases of PTC were identified with median age of 17.0 y and median follow-up of 64.1 mo. Disease recurred at a median of 24.6 mo (range 7.8-78.1) in 7 of 51 (13.7%) of patients with disease limited to the thyroid or central neck, 7 of 18 (39%) patients with lateral neck disease at presentation who underwent a compartment-based resection, and three of three patients (100%) with lateral neck disease who sought care after non-compartment-based resection. There were no deaths from disease. Univariate predictors of recurrence included tumor size2 cm (P = 0.005), lateral neck disease (P = 0.004), lymphovascular invasion (P = 0.017), extracapsular invasion (P 0.0001), multifocality (P = 0.03), and non-Caucasian race (P = 0.05). Multivariate analysis identified race (P = 0.05) as an independent predictor of recurrence. In patients without lateral neck disease, there was a trend toward lower recurrence in patients undergoing thyroidectomy with central neck dissection compared with thyroidectomy alone (P = 0.07).Pediatric PTC is associated with excellent survival, although recurrence is common in patients with lateral node involvement. Predictors of recurrence are multifactorial and may be influenced by extent of disease, patient or tumor biology, and aggressiveness of resection.Prognosis study, level IV, retrospective case series.

PURPOSE: The American College of Surgeons (ACS) recently published quality assurance (QA) indicators for pancreatic cancer care. Implementing quality indicators in a newly formed health system may lead to better patient selection and standardized cancer care. METHODS: Select ACS and internal quality indicators were implemented system wide in 2014. We compared compliance with these measures before and after their implementation at the main hospital and two new affiliate institutions. RESULTS: A total of 506 patients with pancreatic cancer were included. At the main hospital in the pre-QA period, 11 (12.6%) of 87 patients were discussed at our institutional multidisciplinary tumor board meeting; this number rose to 89 (49.7%) of 179 patients ( P < .001) after the implementation. Clinical TNM stage was documented in the electronic medical record in 75 patients (86.2%) in the pre-QA group; this number rose to 170 (94.9%; P = .026) in the post-QA era. External imaging of patients undergoing resection was uploaded in 10 (66.7%) of 15 patient cases in the pre-QA period; this number rose to 33 (93.4%) of 35 ( P = .020). Rates of time from diagnosis to treatment initiation shorter than 60 days were similar between eras (n = 26, 96.3% v n = 57, 95%). Implementation of QA measures at the affiliate institutions did not result in measurable differences. There were no differences in margin-negative resection rate, lymph node yield, or perioperative mortality after QA implementation at any site. CONCLUSION: The implementation of ACS quality indicators at our main hospital was feasible and effective for several measures, without delaying treatment. Instituting these indicators at lower-volume affiliates was more challenging.

International travel continues to steadily increase, including leisure travel, travel to one’s country of origin to visit friends and relatives, travel for service work, and business travel. Travelers with HIV may have an increased risk for travel-associated infections. The pre-travel medical consultation is an important means of assessing one’s risk for travel-related health issues. The aim of this review is to provide an update on key health considerations for the HIV-infected traveler. Like all travelers, the HIV-infected traveler should adhere to behavioral precautions, including safety measures with food and water consumption, safe sexual practices, and arthropod bite avoidance. HIV is a risk factor for venous thromboembolism and patients should be educated regarding this risk. Most pre-travel vaccines are safe and immunogenic in HIV-infected individuals, though live vaccines should be avoided in patients with low CD4 counts. Malaria chemoprophylaxis is strongly recommended in patients with HIV traveling to endemic areas and no significant interactions exist between the commonly used prophylactic anti-malarial agents and anti-retroviral therapy (ART). Travelers with HIV, particularly those who are not on ART or who have low CD4 cell counts, may have increased risk for tuberculosis, malaria, enteric infections, visceral leishmaniasis, American trypanosomiasis, and endemic mycoses such as histoplasmosis, talaromycosis, and coccidioidomycosis. The immune status of the HIV-infected traveler should be assessed prior to travel along with the duration, itinerary, and activities planned during travel in order to carefully consider individual risk for travel-related health issues.

Pleural recurrence after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is rare and poorly delineated. Specifically, data are limited on the effect that diaphragmatic peritoneal stripping versus full-thickness resection has on the nature of ipsilateral pleural recurrence and postoperative morbidity. Patients with peritoneal carcinomatosis who underwent CRS/HIPEC were included from a prospectively maintained database. The patients were divided into three cohorts based on surgical management of the diaphragm as follows: diaphragm-stripping (DS) cohort, full-thickness resection (FTR) cohort, and no diaphragm manipulation (ND) cohort. Postoperative morbidity and incidence of ipsilateral pleural recurrence were evaluated. All diaphragmatic defects were closed before abdominal chemoperfusion. The inclusion criteria were met by 409 CRS/HIPEC procedures: 66 in DS, 122 in FTR, and 238 in ND. Ipsilateral pleural recurrence rates did not differ significantly between the three cohorts (DS 6%, FTR 3%, ND 3%; p = 0.470). Postoperative respiratory complications and overall morbidity were significantly greater for the patients who underwent diaphragmatic disruption (stripping and/or resection) than for the patients who did not (p ≤ 0.0001), but the two groups did not differ in terms of 30-day mortality. However, comparison of FTR with DS showed no impact on major morbidity or pleural recurrence. Although patients undergoing surgical manipulation of the diaphragm during CRS/HIPEC experienced significantly greater morbidity, diaphragmatic stripping did not differ from full-thickness resection in terms of grades 3 and 4 complications or incidence of ipsilateral pleural recurrences. When deemed necessary to achieve complete cytoreduction, full-thickness diaphragmatic resection should be undertaken. In addition, the data support the observation that definitive repair of the diaphragmatic defect before abdominal chemoperfusion does not adversely influence ipsilateral pleural recurrence.

Journalistic and environmentalist discourses casting urban monkeys as outsiders to city landscapes in India appear in concert with efforts to produce a separation between the species through mass translocation of monkeys to beyond city limits. The monkeys are rhesus macaques, and despite popular notions that they are outsiders to human worlds, they exist and sometimes even flourish in the material-symbolic environments of South Asian cities, villages, farms and pastures. Contrary to the predominant discourse on urban monkeys, rhesus at “monkey temples” like Jakhoo Mandir in Shimla demonstrate that nonhuman primates can participate in the production of shared material-semiotic environments. Monkey temples are the products of an adaptive social hybridization at the confluence of coevolutionary interrelation, human religious-ethical sentiment, and the ongoing affective labors of monkeys. The assumption of human political and spatial pre-eminence and its correlative in management practice, mass translocation, are not necessary preconditions for a world in which both humans and monkeys can flourish.

For local activists, the killing of a black South Sudanese refugee by a white officer clearly mirrored the racial violence and police brutality that has shaped the lives of people of color in so many other American cities. For Manyoun’s community of South Sudanese refugees in Louisville, this sentiment is familiar. Refugees resettled in Louisville, as in most American cities, are expected to assimilate into a society in which racial discrimination is widespread, especially when it comes to interactions with the police.

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) is an aggressive locoregional treatment for peritoneal carcinomatosis (PC). Studies demonstrate improved perioperative and oncologic outcomes at high-volume centers. This study retrospectively analyzed all patients with PC from various malignancies who underwent attempted CRS/HIPEC at the authors’ institution from 2007 to 2017. Clinicopathologic, perioperative, and oncologic outcomes of early (2007–2012) and late (2012–2017) experience were compared, and multivariate analyses for factors predictive of perioperative and oncologic outcomes were performed. The study enrolled 388 patients (157 early and 231 late). The late experience contained more appendiceal low-grade mucinous neoplasms (LGMNs; 21% vs 9%) and had a lower Peritoneal Cancer Index (PCI; 10 vs 16). Moreover, achieving a similar rate of CC-0/1 required fewer organ resections, involved shorter operations (298 vs 347 min), and had lower estimated blood loss (EBL) (400 vs 200 ml) (p

Current guidelines recommend harvesting a total lymph node count (TLNC) ≥6 from portal lymphadenectomy in ≥pT1b gallbladder cancers (GBC) for accurate staging and prognostication. This study aimed to determine nodal yields from portal lymphadenectomy and identify measures to maximize TLNC.We retrospectively reviewed all ≥pT1b GBC which underwent resection with curative intent including portal lymphadenectomy at our specialized HPB center from 2007 to 2017. We compared outcomes of TLNC 6 and TLNC ≥ 6 cohorts and determined factors predictive of TLNC.Of 92 patients, 20% had a TLNC ≥ 6 (IQR 7-11) and 9% had no nodes found on pathology. Malignant lymphadenopathy was twice as common in TLNC ≥ 6 as TLNC 6 (p = 0.003) most frequently from portal, cystic and pericholedochal stations. On logistic regression analysis, concomitant liver resection was an independent predictor of higher TLNC [4b/5 wedge resection (OR 0.166, CI 0.057-0.486, p = 0.001) extended hepatectomy (OR 0.065, CI 0.012-0.340, p = 0.001)]; biliary resection and en bloc adjacent organ resection were not.At our center, prior to current guidelines, a TLNC≥6 was not met in 80% undergoing portal lymphadenectomy for ≥ pT1b GBC. To increase nodal yield, future guidelines should consider including additional lymph node stations and incorporation of frozen section analysis.

Colonoscopy to detect colorectal cancer (CRC) is recommended starting at age 50 years; however, CRC rates are increasing in the prescreening population. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) has been proven effective in select patients with peritoneal carcinomatosis (PC) from CRC, although it has not been evaluated specifically in patients

Background: cancellation of planned surgery impacts substantially on patients and health systems. This study describes the incidence and reasons for cancellation of inpatient surgery in the UK NHS. Methods: we conducted a prospective observational cohort study over 7 consecutive days in March 2017 in 245 NHS hospitals. Occurrences and reasons for previous surgical cancellations were recorded. Using multilevel logistic regression, we identified patient- and hospital-level factors associated with cancellation due to inadequate bed capacity. Results: we analysed data from 14 936 patients undergoing planned surgery. A total of 1499 patients (10.0%) reported previous cancellation for the same procedure; contemporaneous hospital census data indicated that 13.9% patients attending inpatient operations were cancelled on the day of surgery. Non-clinical reasons, predominantly inadequate bed capacity, accounted for a large proportion of previous cancellations. Independent risk factors for cancellation due to inadequate bed capacity included requirement for postoperative critical care [odds ratio (OR)=2.92; 95% confidence interval (CI), 2.12–4.02; PConclusions: a significant proportion of patients presenting for surgery have experienced a previous cancellation for the same procedure. Cancer surgery is relatively protected, but bed capacity, including postoperative critical care requirements, are significant risk factors for previous cancellations.

BackgroundMicrobiology laboratory results are complex and cumbersome to review. We sought to develop a new review tool to improve the ease and accuracy of microbiology results review.MethodsWe observed and informally interviewed clinicians to determine areas in which existing microbiology review tools were lacking. We developed a new tool that reorganizes microbiology results by time and organism. We conducted a scenario-based usability evaluation to compare the new tool to existing legacy tools, using a balanced block design.ResultsThe average time-on-task decreased from 45.3 min for the legacy tools to 27.1 min for the new tool (P ConclusionsThe new tool substantially improved efficiency, accuracy, and usability. It was subsequently integrated into the electronic health record and rolled out system-wide. This project provides an example of how clinical and informatics teams can innovative alongside a commercial Electronic Health Record (EHR).

Background While there is a growing body of evidence that suggests outpatient parental antibiotic treatment (OPAT) for people who inject drugs (PWID) may be safe, research on integrating OPAT with addiction treatment for PWID has been limited. Methods Adults hospitalized for infectious complications of injection drug use (IDU) requiring prolonged IV antibiotics were included in this study. The suitability for OPAT was determined by the infectious disease and addiction consultation services. Eligibility criteria included safe housing, attendance at infectious disease (ID) clinic visits, and engagement with addiction treatment. Demographic and clinical outcomes were summarized, and compared with patients without any IDU history enrolled in OPAT during the same time at the same institution. Results Eighteen OPAT episodes among 17 individuals were included, with 9 (50.0%) males. Mean age was 38.4 (SD 9.5). Types of infection included endocarditis (38.9%), epidural abscess (38.9%), and bone/joint infections (33.3%). Opioid use disorders (OUD) were most common (94.4%), followed by cocaine (33.3%) and benzodiazepines (16.7%). All individuals completed the recommended course of IV antibiotics. All OUD patients received buprenorphine (52.9%) or methadone (47.1%). Two (11.1%) relapsed to drug use during OPAT, but no instances of line tampering, thrombosis, line infection or line dislodgement were identified. No deaths or overdoses were reported. Collectively, 504 inpatient days were avoided. Compared with 390 individuals without any history of IDU, those with IDU history were significantly younger (38.4 vs. 59.0, P < 0.0001), had fewer episodes of endocarditis (38.9% vs. 43.6%) and bone/joint infections (33.3% vs. 41.8%), but more epidural abscesses (38.9% vs. 3.1%). There were no statistical differences in rates of readmission (22.2% vs. 11.3%), line complications (0% vs. 3.5%), mortality (0% vs. 1.0%), ID clinic visit attendance (100.0% vs. 82.0%), or number of days on OPAT (28.0 vs. 30.1). Conclusion Results add further evidence of OPAT’s safety among PWID and that integration of addiction treatment may be feasible. OPAT outcomes were similar to those without any IDU history. More research is needed to study the impact of integrating addiction treatment with OPAT for PWID. Disclosures All authors: No reported disclosures.

There is a well-established link between inflammation and cancer of various organs, but little data are available on inflammation-associated markers of diagnostic and prognostic clinical utility in pulmonary malignancy. Blood samples were prospectively collected from 75 resectable lung cancer patients before surgery and in a cohort of 1,358 high-risk subjects. Serum levels of long pentraxin 3 (PTX3) were determined by high-sensitivity ELISA. PTX3 immunostaining was evaluated by immunohistochemistry in cancer tissue. Serum PTX3 levels in the high-risk population were not predictive of developing subsequent lung cancer or any other malignancy; however, serum PTX3 values in patients with lung cancer were significantly higher compared with cancer-free heavy smokers. With a cutoff of 4.5 ng/ml, specificity was 0.80, sensitivity 0.69, positive predictive value 0.15 and negative predictive value 0.98. The receiver operating curve (ROC) for serum PTX3 had an area under the curve (AUC) of 83.52%. Preoperative serum PTX3 levels in lung cancer patients did not correlate with patient outcome, but high interstitial expression of PTX3 in resected tumor specimens was a significant independent prognostic factor associated with shorter survival (p < 0.001). These results support the potential of serum PTX3 as a lung cancer biomarker in high-risk subjects. Furthermore, PTX3 immunohistochemistry findings support the role of local inflammatory mechanisms in determining clinical outcome and suggest that local expression of PTX3 may be of prognostic utility in lung cancer patients.

PURPOSE OF REVIEW We aim to review the strengths and weaknesses of current antiretroviral therapy (ART), and describe ongoing research to address limitations to current therapy. RECENT FINDINGS Current ART is highly effective and well tolerated. As a result of a decrease in medication side-effects and pill burden, and the known health effects of uncontrolled viremia, ART is now recommended at all CD4 cell counts in the USA. Novel medications are being developed to further decrease side-effects and offer alternative options for patients with multiclass resistance. New combination pills will further decrease pill burden. SUMMARY Current treatment for HIV is characterized by highly potent oral antiretroviral medications, which are well tolerated, resulting in outstanding rates of virologic suppression in patients who are adherent to therapy. Despite the marked improvement in therapeutic options, limitations to therapy still exist including reliance on daily adherence, long-term toxicity of medications, drug-drug interactions, long-term effects of HIV even in the setting of viral suppression, high lifetime cost of treatment, and limited options for some patients with multiclass resistance. Emerging alternative treatment strategies include nucleoside reverse transcriptase inhibitor-sparing or limiting regimens and long-acting injectable combination therapy.

We developed a prototype for a closed apparatus for assembling tissue-engineered vascular grafts (TEVGs) with the goal of creating a simple operator-independent method for making TEVGs to optimize safety and enable widespread application of this technology. The TEVG is made by seeding autologous bone marrow-derived mononuclear cells onto a biodegradable tubular scaffold and is the first man-made vascular graft to be successfully used in humans. A critical barrier, which has prevented the widespread clinical adoption of the TEVG, is that cell isolation, scaffold seeding, and incubation are performed using an open method. To reduce the risk of contamination, the TEVG is assembled in a clean room. Clean rooms are expensive to build, complex to operate, and are not available in most hospitals. In this investigation, we used an ovine model to compare the safety and efficacy of TEVGs created using either a standard density centrifugation-based open method or the new filter-based closed system. We demonstrated no graft-related complications and maintenance of growth capacity in TEVGs created using the closed apparatus. In addition, the use of the closed system reduced the amount of time needed to assemble the TEVG by ∼ 50%. Adaptation of similar methodologies may facilitate the safe translation and the widespread use of other tissue engineering technologies.

The interplay between heredity and environment has created this beautiful world which abounds in human diversity. The quality of a child's relationships within the family matters much more than factors such as family size, the number and gender of parents, biology, whether a family is blended or extended, culture, language or religion. The relationships they have from birth help children feel secure, to believe they will be kept safe, and to trust in others and in the world - even when problems arise. Families are the biggest influence on a child's mental health and wellbeing. All children need love, encouragement, and support and especially the differently able children when the parent have a differentially able children in their home they fell depressed, anxious and stress. This study like bring out the highlights in these areas. The standard scale was used to assess the depression, anxiety and stress (DASS 42) Lovibond and lovidond (1995) and researcher intended to study the level of depression, anxiety and stress which is experienced by 86 parents of children with differently abled children and the findings reveals that among Depression, Anxiety and stress, the number of parents experiencing anxiety is found to be high, which may be because the parents tend to be worried more about their children's future. As their children grow and even the parents getting old, the parents tend to be more anxious because they are affected with a fear that what would happen after their absence owing to death or inability to care for their wards.

Bilirubin acts as a potent endogenous antioxidant, with higher concentrations associated with lower rates of CVD; the antiretroviral drug atazanavir (ATV) increases bilirubin levels but may also increase von Willebrand factor levels. We tested the hypothesis that increasing endogenous bilirubin using ATV would improve cardiometabolic risk factors and vascular function in older patients with HIV. Ninety participants were enrolled in two study protocols. In protocol 1, we evaluated markers of inflammation, thrombosis, and conduit artery endothelial function in subjects on non-ATV containing regimens. Participants were randomly assigned to continue baseline treatment or switch to an ATV-based regimen. Measurements were made at baseline and 28 days. In the protocol 2, we enrolled 30 subjects who received atazanavir for more than one year and were compared to the aim 1 protocol subjects at baseline. 60 subjects were enrolled in the first protocol (mean age 53, +/- 6 years), with 31 randomized to ATV and 29 continuing baseline treatment. Atazanavir significantly increased serum total bilirubin levels (pTrial registrationClinicalTrials.gov NCT03019783.