Background
This case highlights challenges in the assessment and management of the “difficult airway” patient in the SARS‐CoV‐2 (COVID‐19) pandemic era.
Methods
A 60‐year‐old male with history of ...recent transoral robotic surgery resection, free flap reconstruction, and tracheostomy for p16+ squamous cell carcinoma presented with stridor and dyspnea 1 month after decannulation. Careful planning by a multidisciplinary team allowed for appropriate staffing and personal protective equipment, preparations for emergency airway management, evaluation via nasopharyngolaryngoscopy, and COVID testing. The patient was found to be COVID negative and underwent imaging which revealed new pulmonary nodules and a tracheal lesion.
Results
The patient was safely transorally intubated in the operating room. The tracheal lesion was removed endoscopically and tracheostomy was avoided.
Conclusions
This case highlights the importance of careful and collaborative decision making for the management of head and neck cancer and other “difficult airway” patients during the COVID‐19 epidemic.
The ocean is key to understanding societal threats including climate change, sea level rise, ocean warming, tsunamis, and earthquakes. Because the ocean is difficult and costly to monitor, we lack ...fundamental data needed to adequately model, understand, and address these threats. One solution is to integrate sensors into future undersea telecommunications cables. This is the mission of the SMART subsea cables initiative (Science Monitoring And Reliable Telecommunications). SMART sensors would “piggyback” on the power and communications infrastructure of a million kilometers of undersea fiber optic cable and thousands of repeaters, creating the potential for seafloor-based global ocean observing at a modest incremental cost. Initial sensors would measure temperature, pressure, and seismic acceleration. The resulting data would address two critical scientific and societal issues: the long-term need for sustained climate-quality data from the under-sampled ocean (e.g., deep ocean temperature, sea level, and circulation), and the near-term need for improvements to global tsunami warning networks. A Joint Task Force (JTF) led by three U.N. agencies (ITU/WMO/UNESCO-IOC) is working to bring this initiative to fruition. This paper explores the ocean science and early warning improvements available from SMART cable data, and the societal, technological, and financial elements of realizing such a global network. Simulations show that deep ocean temperature and pressure measurements can improve estimates of ocean circulation and heat content, and cable-based pressure and seismic-acceleration sensors can improve tsunami warning times and earthquake parameters. The technology of integrating these sensors into fiber optic cables is discussed, addressing sea and land-based elements plus delivery of real-time open data products to end users. The science and business case for SMART cables is evaluated. SMART cables have been endorsed by major ocean science organizations, and JTF is working with cable suppliers and sponsors, multilateral development banks and end-users to incorporate SMART capabilities into future cable projects. By investing now, we can build up a global ocean network of long-lived SMART cable sensors, creating a transformative addition to the global ocean observing system.
The proposed introduction of gaming disorder (GD) in the 11th revision of the International Classification of Diseases (ICD-11) developed by the World Health Organization (WHO) has led to a lively ...debate over the past year. Besides the broad support for the decision in the academic press, a recent publication by van Rooij et al. (2018) repeated the criticism raised against the inclusion of GD in ICD-11 by Aarseth et al. (2017). We argue that this group of researchers fails to recognize the clinical and public health considerations, which support the WHO perspective. It is important to recognize a range of biases that may influence this debate; in particular, the gaming industry may wish to diminish its responsibility by claiming that GD is not a public health problem, a position which maybe supported by arguments from scholars based in media psychology, computer games research, communication science, and related disciplines. However, just as with any other disease or disorder in the ICD-11, the decision whether or not to include GD is based on clinical evidence and public health needs. Therefore, we reiterate our conclusion that including GD reflects the essence of the ICD and will facilitate treatment and prevention for those who need it.
Objective
: The aim of this study was to examine how calibration uncertainty affects the overall uncertainty of a mathematical model and to evaluate potential drivers of calibration uncertainty.
...Methods
: A lifetime Markov model of the natural history of human papillomavirus (HPV) infection and cervical disease was developed to assess the cost effectiveness of a hypothetical HPV vaccine. Published data on cervical cancer incidence and mortality and prevalence of pre-cursor lesions were used as endpoints to calibrate the age- and HPV-type-specific transition probabilities between health states using the Nelder-Mead simplex method of calibration. A conventional probabilistic sensitivity analysis (PSA) was performed to assess uncertainty in vaccine efficacy, cost and utility estimates. To quantify the uncertainty around calibrated transition probabilities, a second PSA (calibration PSA) was performed using 25 distinct combinations of objective functions and starting simplexes.
Results
: The initial calibration produced an incremental cost-effectiveness ratio (ICER) of $US4300 per QALY for vaccination compared with no vaccination, and the conventional PSA gave a 95% credible interval of dominant to $US9800 around this estimate (2005 values). The 95% credible interval for the ICERs in the calibration PSA ranged from $US1000 to $US37 700.
Conclusions
: Compared with a conventional PSA, the calibration PSA results reveal a greater level of uncertainty in cost-effectiveness results. Sensitivity analyses around model calibration should be performed to account for uncertainty arising from the calibration process.
IMPORTANCE: Compared with enalapril, sacubitril-valsartan reduces cardiovascular mortality and heart failure hospitalization in patients with heart failure and reduced ejection fraction (HFrEF). ...These benefits may be related to effects on hemodynamics and cardiac remodeling. OBJECTIVE: To determine whether treatment of HFrEF with sacubitril-valsartan improves central aortic stiffness and cardiac remodeling compared with enalapril. DESIGN, SETTING, AND PARTICIPANTS: Randomized, double-blind clinical trial of 464 participants with heart failure and ejection fraction of 40% or less enrolled across 85 US sites between August 17, 2016, and June 28, 2018. Follow-up was completed on January 26, 2019. INTERVENTIONS: Randomization (1:1) to sacubitril-valsartan (n = 231; target dosage, 97/103 mg twice daily) vs enalapril (n = 233; target dosage, 10 mg twice daily) for 12 weeks. MAIN OUTCOMES AND MEASURES: The primary outcome was change from baseline to week 12 in aortic characteristic impedance (Zc), a measure of central aortic stiffness. Prespecified secondary outcomes included change from baseline to week 12 in N-terminal pro–B-type natriuretic peptide, ejection fraction, global longitudinal strain, mitral annular relaxation velocity, mitral E/e′ ratio, left ventricular end-systolic and end-diastolic volume indexes (LVESVI and LVEDVI), left atrial volume index, and ventricular-vascular coupling ratio. RESULTS: Of 464 validly randomized participants (mean age, 67.3 SD, 9.1 years; 23.5% women), 427 completed the study. At 12 weeks, Zc decreased from 223.8 to 218.9 dyne × s/cm5 in the sacubitril-valsartan group and increased from 213.2 to 214.4 dyne × s/cm5 in the enalapril group (treatment difference, −2.2 95% CI, −17.6 to 13.2 dyne × s/cm5; P = .78). Of 9 prespecified secondary end points, no significant between-group difference in change from baseline was seen in 4, including left ventricular ejection fraction (34%-36% with sacubitril-valsartan vs 33 to 35% with enalapril; treatment difference, 0.6% 95% CI, −0.4% to 1.7%; P = .24). However, greater reductions from baseline were seen with sacubitril-valsartan than with enalapril in all others, including left atrial volume (from 30.4 mL/m2 to 28.2 mL/m2 vs from 29.8 mL/m2 to 30.5 mL/m2; treatment difference, −2.8 mL/m2 95% CI, −4.0 to −1.6 mL/m2; P < .001), LVEDVI (from 75.1 mL/m2 to 70.3 mL/m2 vs from 79.1 mL/m2 to 75.6 mL/m2; treatment difference, −2.0 mL/m2 95% CI, −3.7 to 0.3 mL/m2; P = .02), LVESVI (from 50.8 mL/m2 to 46.3 mL/m2 vs from 54.1 to 50.6 mL/m2; treatment difference, −1.6 mL/m2 95% CI, −3.1 to −0.03 mL/m2; P = .045), and mitral E/e′ ratio (from 13.8 to 12.3 vs from 13.4 to 13.8; treatment difference, −1.8 95% CI, −2.8 to −0.8; P = .001). Rates of adverse events including hypotension (1.7% vs 3.9%) were similar in both groups. CONCLUSIONS AND RELEVANCE: Treatment of HFrEF with sacubitril-valsartan, compared with enalapril, did not significantly reduce central aortic stiffness. The study findings may provide insight into mechanisms underlying the effects of sacubitril-valsartan in HFrEF. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02874794
To evaluate the utility of transcript profiling for prediction of protein expression levels, we compared profiles across the NCI-60 cancer cell panel, which represents nine tissues of origin. For ...that analysis, we present here two new NCI-60 transcript profile data sets (A based on Affymetrix HG-U95 and HG-U133A chips; Affymetrix, Santa Clara, CA) and one new protein profile data set (based on reverse-phase protein lysate arrays). The data sets are available online at http://discover.nci.nih.gov in the CellMiner program package. Using the new transcript data in combination with our previously published cDNA array and Affymetrix HU6800 data sets, we first developed a "consensus set" of transcript profiles based on the four different microarray platforms. Using that set, we found that 65% of the genes showed statistically significant transcript-protein correlation, and the correlations were generally higher than those reported previously for panels of mammalian cells. Using the predictive analysis of microarray nearest shrunken centroid algorithm for functional prediction of tissue of origin, we then found that (a) the consensus mRNA set did better than did data from any of the individual mRNA platforms and (b) the protein data seemed to do somewhat better (P = 0.027) on a gene-for-gene basis in this particular study than did the consensus mRNA data, but both did well. Analysis based on the Gene Ontology showed protein levels of structure-related genes to be well predicted by mRNA levels (mean r = 0.71). Because the transcript-based technologies are more mature and are currently able to assess larger numbers of genes at one time, they continue to be useful, even when the ultimate aim is information about proteins.
Phosphatidylinositol 3-kinase (PI3-K) signalling pathway is a crucial path in cancer for cell survival and thus represents an intriguing target for new paediatric anti-cancer drugs. However, the ...unique clinical toxicities of targeting this pathway (resulting in hyperglycaemia) difficulties combining with chemotherapy, rarity of mutations in childhood tumours and concomitant mutations have resulted in major barriers to clinical translation of these inhibitors in treating both adults and children. Mutations in PIK3CA predict response to PI3-K inhibitors in adult cancers. The same mutations occur in children as in adults, but they are significantly less frequent in paediatrics. In children, high-grade gliomas, especially diffuse midline gliomas (DMG), have the highest incidence of PIK3CA mutations. New mutation-specific PI3-K inhibitors reduce toxicity from on-target PI3-Kα wild-type activity. The mTOR inhibitor everolimus is approved for subependymal giant cell astrocytomas. In paediatric cancers, mTOR inhibitors have been predominantly evaluated by academia, without an overall strategy, in empiric, mutation-agnostic clinical trials with very low response rates to monotherapy. Therefore, future trials of single agent or combination strategies of mTOR inhibitors in childhood cancer should be supported by very strong biological rationale and preclinical data. Further preclinical evaluation of glycogen synthase kinase-3 beta inhibitors is required. Similarly, even where there is an AKT mutation (∼0.1 %), the role of AKT inhibitors in paediatric cancers remains unclear. Patient advocates strongly urged analysing and conserving data from every child participating in a clinical trial. A priority is to evaluate mutation-specific, central nervous system-penetrant PI3-K inhibitors in children with DMG in a rational biological combination. The choice of combination, should be based on the genomic landscape e.g. PTEN loss and resistance mechanisms supported by preclinical data. However, in view of the very rare populations involved, innovative regulatory approaches are needed to generate data for an indication.
•PI3-K pathway mutations are rare in paediatrics, with the highest frequency in DMG.•New trials of mTOR inhibitors should be supported by strong biological rationale.•Toxicities and lack of activity have been major barriers to clinical translation.•New mutation-specific inhibitors in combination, may greatly increase activity.•Evaluating mutation-specific, CNS penetrant, inhibitors in DMG is a priority.
Background and objectiveSimulation models can project effects of tobacco use and cessation and inform tobacco control policies. Most existing tobacco models do not explicitly include relapse, a key ...component of the natural history of tobacco use. Our objective was to develop, calibrate and validate a novel individual-level microsimulation model that would explicitly include smoking relapse and project cigarette smoking behaviours and associated mortality risks.MethodsWe developed the Simulation of Tobacco and Nicotine Outcomes and Policy (STOP) model, in which individuals transition monthly between tobacco use states (current/former/never) depending on rates of initiation, cessation and relapse. Simulated individuals face tobacco use-stratified mortality risks. For US women and men, we conducted cross-validation with a Cancer Intervention and Surveillance Modeling Network (CISNET) model. We then incorporated smoking relapse and calibrated cessation rates to reflect the difference between a transient quit attempt and sustained abstinence. We performed external validation with the National Health Interview Survey (NHIS) and the linked National Death Index. Comparisons were based on root-mean-square error (RMSE).ResultsIn cross-validation, STOP-generated projections of current/former/never smoking prevalence fit CISNET-projected data well (coefficient of variation (CV)-RMSE≤15%). After incorporating smoking relapse, multiplying the CISNET-reported cessation rates for women/men by 7.75/7.25, to reflect the ratio of quit attempts to sustained abstinence, resulted in the best approximation to CISNET-reported smoking prevalence (CV-RMSE 2%/3%). In external validation using these new multipliers, STOP-generated cumulative mortality curves for 20-year-old current smokers and never smokers each had CV-RMSE ≤1% compared with NHIS. In simulating those surveyed by NHIS in 1997, the STOP-projected prevalence of current/former/never smokers annually (1998–2009) was similar to that reported by NHIS (CV-RMSE 12%).ConclusionsThe STOP model, with relapse included, performed well when validated to US smoking prevalence and mortality. STOP provides a flexible framework for policy-relevant analysis of tobacco and nicotine product use.
Mycobacterium tuberculosis (Mtb) is an obligate aerobe that is capable of long-term persistence under conditions of low oxygen tension. Analysis of the Mtb genome predicts the existence of a branched ...aerobic respiratory chain terminating in a cytochrome bd system and a cytochrome aa3system. Both chains can be initiated with type II NADH:menaquinone oxidoreductase. We present a detailed biochemical characterization of the aerobic respiratory chains from Mtb and show that phenothiazine analogs specifically inhibit NADH:menaquinone oxidoreductase activity. The emergence of drug-resistant strains of Mtb has prompted a search for antimycobacterial agents. Several phenothiazines analogs are highly tuberculocidal in vitro, suppress Mtb growth in a mouse model of acute infection, and represent lead compounds that may give rise to a class of selective antibiotics.
Background
: A recent study found fewer hospitalizations for congestive heart failure (CHF) patients receiving high-dose versus low-dose statin therapy.
Objective
: To examine the cost effectiveness ...of high-dose versus low-dose statin therapy in CHF patients.
Methods
: Two scenarios (literature-based base-case scenario vs trial-based post-event mortality alternative scenario) assessed the cost effectiveness of atorvastatin 80mg/day (A80) versus atorvastatin 10 mg/day (A10) in patients with both CHF and coronary heart disease (CHD) CHF/CHD, using a lifetime Markov model. The model predicts treatment-specific probabilities of major and minor cardiovascular events and death, based on clinical trial data. The quality of life and costs were literature based. Measures included costs per life-year saved (LYS) and QALY gained. Health consequences and costs were discounted at 3.0% annually. Analyses were conducted from the payer perspective and valued in $US, year 2006–7 values.
Results
: Literature-based mortality estimates (base case) increased life-years and QALYs for A80 compared with A10 (incremental cost-effectiveness ratios ICERs: $US9600 per LYS; $US13 600 per QALY). At a willingness to pay of $US100 000 per QALY, A80 was cost effective in 80% of simulations.
A10 dominated A80 when using trial-based mortality estimates (alternative scenario). At a willingness to pay of $US100 000 per QALY, A80 was cost effective in 48% of simulations.
Conclusions
: Intensive A80 treatment may be cost effective versus A10 in cardiovascular prevention in CHF/CHD patients in the US, due to projected gains in life expectancy and health-related quality of life. However, the results are highly sensitive to assumptions about the mortality rate in the model. When using the mortality rate observed in the trial, A10 dominates A80.
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