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A meeting of experts was held in November 2021 to review and discuss available data on performance of Epstein-Barr virus (EBV)–based approaches to screen for early stage nasopharyngeal carcinoma (NPC) and methods for the investigation and management of screen-positive individuals. Serum EBV antibody and plasma EBV DNA testing methods were considered. Both approaches were found to have favorable performance characteristics and to be cost-effective in high-risk populations. In addition to endoscopy, use of magnetic resonance imaging (MRI) to investigate screen-positive individuals was found to increase the sensitivity of NPC detection with minimal impact on cost-effectiveness of the screening program.

ImportanceSingle ventricle CHD affects about 5 out of 100,000 newborns, resulting in complex anatomy often requiring multiple, staged palliative surgeries. Paediatricians are an essential part of the team that cares for children with single ventricle CHD. These patients often encounter their paediatrician first when a complication arises, so it is critical to ensure the paediatrician is knowledgeable of these issues to provide optimal care.ObservationsWe reviewed the subtypes of single ventricle heart disease and the various palliative surgeries these patients undergo. We then searched the literature to detail the general paediatrician’s approach to single ventricle patients at different stages of surgical palliation.Conclusions and relevanceSingle ventricle patients undergo staged palliation that drastically changes physiology after each intervention. Coordinated care between their paediatrician and cardiologist is requisite to provide excellent care. This review highlights what to expect when these patients are seen by their paediatrician for either well child visits or additional visits for parental or patient concern.

The COVID-19 pandemic catalyzed the integration of a virtual education curriculum to support radiation oncologists in training. We report outcomes from Radiation Oncology Virtual Education Rotation (ROVER) 2.0, a supplementary virtual educational curriculum created for radiation oncology residents globally. A prospective cohort of residents completed surveys before and after the live virtual webinar sessions (pre- and post-surveys, respectively). Live sessions were structured as complex gray-zone cases across various core disease sites. Resident demographics and responses were summarized using means, standard deviations, and proportions. Nine ROVER sessions were held from October 2020 to June 2021. A total of 1487 registered residents completed the pre-survey, of which 786 attended the live case discussion and 223 completed post-surveys. A total of 479 unique radiation oncology residents (of which 95, n = 19.8%, were international attendees) from 147 institutions (national, n = 81, 55.1%; international, n = 66, 44.9%) participated in the sessions. There was similar participation across post-graduate year (PGY) 2 through 5 (range n = 86 to n = 105). Of the 122 unique resident post-surveys, nearly all reported learning through the virtual structure as "very easy" or "easy" (97.5%, n = 119). A majority rated the ROVER 2.0 educational sessions to be "valuable or "very valuable" (99.2%, n = 121), and the panelists-attendee interaction as "appropriate" (97.5%, n = 119). Virtual live didactics aimed at radiation oncology residents are feasible. These results suggest that the adoption of the ROVER 2.0 curricula may help improve radiation oncology resident education.

Mitral valve replacement in neonates and infants is a challenging operation with few good options. Neo-mitral valve reconstruction with right atrial appendage (RAA) may overcome some of the limitations of existing options.

Pericentromeric heterochromatin is highly enriched for repetitive sequences prone to aberrant recombination. Previous studies showed that homologous recombination (HR) repair is uniquely regulated in this domain to enable ‘safe’ repair while preventing aberrant recombination. InDrosophilacells, DNA double-strand breaks (DSBs) relocalize to the nuclear periphery through nuclear actin-driven directed motions before recruiting the strand invasion protein Rad51 and completing HR. End-joining (EJ) repair also occurs with high frequency in heterochromatin of fly tissues, but how different EJ pathways operate in heterochromatin remains uncharacterized. Here, we induce DSBs in single euchromatic and heterochromatic sites using the DR-whitereporter and I-SceI expression in spermatogonia. We detect higher frequency of HR repair in heterochromatic insertions, relative to euchromatin. Sequencing of repair outcomes reveals the use of distinct EJ pathways across different euchromatic and heterochromatic sites. Interestingly, synthesis-dependent michrohomology-mediated end joining (SD-MMEJ) appears differentially regulated in the two domains, with a preferential use of motifs close to the cut site in heterochromatin relative to euchromatin, resulting in smaller deletions. Together, these studies establish a new approach to study repair outcomes in fly tissues, and support the conclusion that heterochromatin uses more HR and less mutagenic EJ repair relative to euchromatin.

Introduction The severity of internal carotid artery (ICA) atherosclerosis is assessed through measurements of degree of stenosis. This approach does not factor in mechanisms compensating for reduced distal perfusion, such as collateral circulation. An alternative approach is evaluating severity of carotid stenosis based on downstream changes in ocular perfusion. Laser speckle flowgraphy (LSFG) is a non‐invasive tool that quantifies intraocular blood flow. This pilot study investigated whether LSFG metrics could be surrogates for degree of stenosis. Additionally, we quantified changes in flow through the stenosed vessel before and after stenting usingsyngoiFlow (iFlow). Methods Fourteen patients had stents placed to treat symptomatic carotid stenosis. LSFG metrics were obtained before and after stenting. Mean blur rate (MBR), an index of ocular blood velocity, and associated waveform parameters were extracted from the optic nerve head (ONH) region of the eye. iFlow quantified time to peak (TTP), an index of peak cerebral contrast flow, by transforming digital subtraction angiography (DSA) images into perfusion heat maps.TTPswere extracted for seven regions of interest (ROIs) by two raters. Results Two LSFG waveform parameters were significantly negatively correlated with degree of stenosis. These parameters, flow acceleration index (FAI) and rising rate (RR), also increased significantly after stenting. Intraclass correlation coefficients calculated for TTPs showed substantial agreement across all ROIs. Significant decreases in TTP after stenting were observed in ROIs placed in the high cervical ICA, cavernous segment of the ICA, and brain parenchyma. Conclusions LSFG provides biometrics that can accurately measure the impact of ICA stenosis by quantifying distal perfusion. Indices of ocular blood flow acceleration may serve as surrogate metrics for degree of stenosis. iFlow is a sensitive tool to quantify changes in flow after stenting. Non‐invasive flow‐dependent methods are promising in the assessment of patients with ICA stenosis.

Introduction Aneurysmal subarachnoid hemorrhage (aSAH) can lead to life‐threatening complications such as vasospasm and hydrocephalus. The incidence of these events is influenced by the volume of intracranial hemorrhage. The Fisher score is a subjective adjudication of SAH volume. We developed an objective semi‐automated method to quantify the volume of intracranial hemorrhage. Moreover, we evaluated the association of aSAH volume with vasospasm and hydrocephalus. Methods A custom semi‐automated image segmentation algorithm quantifying aSAH volume was implemented in MATLAB. The volume of hemorrhage was retrospectively measured from non‐contrast brain CT scans with Fisher grade ≥ 2. The algorithm utilized region‐growing and 3D k‐means clustering. Performance was validated against the average of two sets of hemorrhage volumes manually measured. These measurements were obtained from two independent raters who selected regions of interest spanning areas of hemorrhage. The association between blood volume and clinical outcome (hydrocephalus or vasospasm) was evaluated using ROC analysis. Results Fifty‐seven patients were included in this study and 10 patients were used for validation of our method. The ICC between raters for manual measurements of hemorrhage in the validation group was 0.988 (CI: (0.911, 0.997), p < 0.001). Validation of semi‐automated versus manual methods resulted in an ICC of 0.961 (CI: (0.756, 0.991), p < 0.001). Bland‐Altman analysis revealed that the algorithm slightly underestimated blood volume (mean difference = ‐4.11 mL). Hemorrhage volume discriminated for the development of vasospasm (AUC = 0.781) and hydrocephalus (AUC = 0.776). Conclusions Volume of hemorrhage is a key factor that influences the incidence of complications in aSAH. We developed and validated a semi‐automated algorithm for quantifying the volume of aSAH. Vasospasm and hydrocephalus were associated with greater amounts of intracranial blood. Objective measurements of aSAH volume can aid in adjudicating risk of complications among patients with aSAH.

Heart-lung transplantation has historically been used as a definitive treatment for children with end-stage cardiopulmonary failure, although the number performed has steadily decreased over time. In this review, we discuss current indications, preoperative risk factors, outcomes, and heart-lung transplantation in unique patient subsets, including infants, children with single-ventricle physiology, tetralogy of Fallot/major aortopulmonary collateral arteries, and prior Potts shunt palliation. We also describe the different surgical techniques utilized in pediatric heart-lung transplantation.

Management strategies for congenitally corrected transposition of the great arteries (ccTGA) historically consisted of a physiologic repair, resulting in the morphologic right ventricle (mRV) supporting systemic circulation. This strategy persisted despite the development of heart failure by middle age because of the reasonable short-term outcomes, and the natural history of some patients with favorable anatomy (felt to demonstrate the mRV's ability to function in the long-term), and due to the less-than-optimal outcomes associated with anatomical repair. As outcomes with anatomical repair improved, and the long-term risk of systemic mRV dysfunction became apparent, more have begun to realize its advantages. In addition to the decision on whether or not to pursue anatomical repair, and the optimal timing, studies demonstrating the nuance to morphologic left ventricle retraining have demonstrated its feasibility. Further considerations in ccTGA have begun to be better understood, including: the management of a poorly functioning mRV, systemic tricuspid valve regurgitation, the utility of morphologic left ventricle outflow tract obstruction (native or surgically created) and pacing strategies. While some considerations are apparent: biventricular pacing is superior to univentricular, tricuspid regurgitation must be managed early with either progression towards anatomical repair (pulmonary artery banding if needed for retraining) or tricuspid replacement (not repair) based on the patient's age; others remain to be completely elucidated. Overall, the heterogeneity of ccTGA, as well as the unique presentation with each patient regarding ventricular and valvular function and center-to-center variability in management strategies has made the interpretation of published data difficult. That said, more recent long-term outcomes favor anatomical repair in most situations.

Introduction: Robust evidence suggest that aneurysmal subarachnoid hemorrhage (aSAH) triggers a potent respone from innate and adaptive inmunities. An increase in CD8+CD161+ cells has been observed in the acute phase of patients with aSAH. However, the role of this cells is poorly understood. Methods: Cerebrospinal fluid of patients with aSAH and non-aneurysmal SAH (nasSAH) was analyzed. Single cell RNA sequencing (scRNAseq) of CD8+CD161+ cells sorted from the CSF of patients with aSAH was performed. Specific cell populations were identified based on gene clustering. Additionaly ten genes were identified. The levels of these genes were then quantified with real-time quantitative polymerase chain reaction (RT- qPCR) and were compared in patients with aSAH and patients with naSAH. Finally highly expressed proteins were quantified with ELISA. Results: Gene clustering suggested that CD14+ monocytes, NK cells and T cells expressed CD8+CD161+ in the CSF of patients with aSAH. Ten differentially expressed genes of clinical interest were then identified: CCL55, CCL7, APOE, SPP1, CXCL8, CXCL10, HMOX1, LTB, MAL, HLA-DRA1/HLA-DRB1 and their mRNA levels were quantied. CXCL10 and HMOX1 levels were higher in aSAH samples than in naSAH (p=0.02 and p=0.076, respectively). CXCL10 was the most significantly different expressed gene in aSAH compared to naSAH samples, and it was chosen for further analysis with ELISA. Protein levels of CXCL10 were higher in patients with aSAH [median(IQR) = 598(635) pg/mL] compared to patients with naSAH [median(IQR) = 31(214) pg/mL, p=0.04]. Conclusion: CD14+ monocytes, NK cells and T cells are CD8+CD161+ in patients with aSAH. CD14+ may be involved in the inflammatory response after aSAH through the expression of the pro-inflammatory cytokine CXCL10.

Introduction: Hemorrhage volume affects the risk of developing complications after aneurysmal subarachnoid hemorrhage (aSAH). This volume is quantified subjectively through the Fisher Scale. We developed an automated method to quantify intracranial hemorrhage and determine the risk of complications after aSAH. Methods: CT scans of patients with aSAH were analyzed. An image-processing algorithm was designed in MATLAB to quantify aSAH volume. The automated algorithm was developed with region-growing and 3D k-means clustering. Two independent raters manually measured hemorrhage volumes using PACS and correlated these measurements with the algorithm measurements in ten patients. Vasospasm and hydrocephalus were identified through chart and imaging review. Hydrocephalus was adjudicated as ventricular enlargement in the setting of aSAH. ROC analysis was performed to evaluate the association between blood volume and the incidence of vasospasm, hydrocephalus and need for a permanent ventriculoperitoneal (VP) shunt. Results: One hundred and forty-one patients were included in the analysis. The intraclass coefficient correlation (ICC) for inter-rater agreement in PACS was 0.988 (p < 0.001). The ICC for comparing automated versus manual volumes was 0.966 (p < 0.001). Bland-Altman analysis reported a mean difference of -3.14 mL between automated and manual measurements. Hemorrhage volume discriminated for the development of vasospasm (AUC = 0.692), hydrocephalus (AUC = 0.775), and need of permanent VP shunt (AUC = 0.669). Conclusion: Vasospasm and hydrocephalus were associated with higher volume of aSAH. Patients with higher volume of aSAH at presentation were more likely to require a permanent VP shunt. An objective method to automatically measure aSAH volume can aid in assessing risk of complications among patients with aSAH.

Introduction: The enhancement of atherosclerotic plaques after the intravenous administration of gadolinium (Gd) has been correlated with the presence of culprit plaques in patients with acute strokes due to underlying intracranial atherosclerosis (ICAS). A new method to objectively quantify Gd-enhancement was used to monitor plaques over time after an acute stroke. Currently there is no imaging method to accurately monitor atherosclerotic activity. Methods: Patients with stroke or transient ischemic attack caused by ICAS were included. Every patient was started on high-dose statins after ictus. 7T MRI images were obtained at baseline and after at least 6 months. LDL levels were obtained at the time of the event and at follow-up. Culprit plaques were identified based on degree of stenosis, presence of positive remodeling and Gd-enhancement. Arterial 3D enhancement maps in the territory of the culprit plaque were generated. Orthogonal signal intensity (SI) probes were expanded into the plaque and parent vessel to generate 3D enhancement color maps. Arterial segment variance (ASV) (SD 2 Arterial segment Baseline T1+Gd - SD 2 Arterial segment Follow up T1+Gd ) was used to compare the plaque and parent vessel enhancement. Results: Five patients underwent baseline and follow-up imaging. The median time between scans was 13.3 (IQR=13.3) months. ASV was strongly correlated with changes in LDL (Rho=0.9, p=0.037). Additionally, Gd-enhancement and plaque burden correlated with levels of LDL (Figure): Gd uptake (Rho=0.7, p=0.22) and plaque burden (Rho=0.67, p=0.22). Conclusion: This pilot study demonstrates that high-resolution imaging can be used in determining the response to statins in patients with high atherosclerotic burden. Gd-enhancement and plaque burden correlated with serum values of LDL. 3D enhancement maps and histogram analysis of atherosclerotic plaques are promising tools for evaluating disease activity and response to medical therapy.

Many cardiac diseases are characterized by an increased late sodium current, including heart failure, hypertrophic cardiomyopathy, and inherited long QT syndrome type 3 (LQT3). The late sodium current in LQT3 is caused by a gain-of-function mutation in the voltage-gated sodium channel Nav1.5. Despite a well-defined genetic cause of LQT3, treatment remains inconsistent because of incomplete penetrance of the mutation and variability of antiarrhythmic efficacy. Here, we investigate the relationship between LQT3-associated mutation incomplete penetrance and variability in ion channel expression, simulating a population of 1,000 individuals with the O'Hara-Rudy model of the human ventricular myocyte. We first simulate healthy electrical activity (i.e., in the absence of a mutation) and then incorporate heterozygous expression for three LQT3-associated mutations (Y1795C, I1768V, and ΔKPQ), to directly compare the effects of each mutation on individuals across a diverse population. For all mutations, we find that susceptibility, defined by either the presence of an early afterdepolarization (EAD) or prolonged action potential duration (APD), primarily depends on the balance between the conductance of

The relationship between lipid homeostasis and protein homeostasis (proteostasis) is complex and remains incompletely understood. We conducted a screen for genes required for efficient degradation ofDeg1-Sec62, a model aberrant translocon-associated substrate of the endoplasmic reticulum (ER) ubiquitin ligase Hrd1, inSaccharomyces cerevisiae. This screen revealed thatINO4is required for efficientDeg1-Sec62 degradation.INO4encodes one subunit of the Ino2/Ino4 heterodimeric transcription factor, which regulates expression of genes required for lipid biosynthesis.Deg1-Sec62 degradation was also impaired by mutation of genes encoding several enzymes mediating phospholipid and sterol biosynthesis. The degradation defect inino4Δ yeast was rescued by supplementation with metabolites whose synthesis and uptake are mediated by Ino2/Ino4 targets. Stabilization of a panel of substrates of the Hrd1 and Doa10 ER ubiquitin ligases byINO4deletion indicates ER protein quality control is generally sensitive to perturbed lipid homeostasis. Further, loss ofINO4sensitized yeast to proteotoxic stress, suggesting a broad requirement for lipid homeostasis in maintaining proteostasis. Abundance of the ER ubiquitin-conjugating enzyme Ubc7 was reduced in the absence ofINO4, consistent with a model whereby perturbed lipid biosynthesis alters the abundance of critical protein quality control mediators, with broad consequences for ER proteostasis. A better understanding of the dynamic relationship between lipid homeostasis and proteostasis may lead to improved understanding and treatment of several human diseases associated with altered lipid biosynthesis.