United States

Abstract Title: Efficiency of IES device in facilitating distraction enterogenesis for treating short gut syndrome.

Background
Short gut syndrome (SGS) is intestinal failure because of inadequate intestinal length often encountered by pediatric surgeons. In SGS, gut adaptation and enteral absorption is low, often requiring long term parenteral nutrition for adequate development. This poses increased risk for complications including line sepsis, necrotizing enterocolitis, and liver failure. Surgical options like small bowel implantation pose significant risks and often provide limited gut expansion. We aim to experimentally evaluate the efficiency of the intestinal expansion sleeve (IES) in determining lengthening of the native bowel. We hypothesize that intestinal expansion commensurate to the IES compression can be achieved already at time of surgery.

Methods
IES devices were made using proprietary cylindrical material with helicoid trusses and isometric ends measuring 30mm in length. Ends of the device were coated with a barium-sealant mixture preventing distress and improved visualization after placement. IES devices were pre-contracted over a dilator, leading to diametric expansion. Mechanical characterization of IES devices and native small intestine segments were performed using an Instron 8874 Biaxial servo hydraulic fatigue testing system. IES devices were implanted in ex vivo intestinal segments of Sprague Dawley rats. Post-deployment gut expansion was measured using calipers. Lastly, histological analysis of the gut tissue was performed for native and experimental tissue following IES removal.

Results
IES devices deployed in rat small intestine immediately produced lengthening of 2.17 ± .17cm to 2.75 ± .22cm (p&lt;.001, n=11). Mechanical characterization demonstrated IES exerted longitudinal forces of 0.13 ± 0.01 N to 0.22 ± 0.01 N upon expansion to post deployment length. Mechanical characterization of native small bowel demonstrated that forces greater than 1.88 ± .21 N produced rupturing of the tissue. The data proves IES devices provide significant expansion without risk of small intestinal failure. Histological examination showed significantly decreased thickness of serosal, muscular, and mucosal layers of the small intestine. 

Conclusion
This study shows that distraction enterogenesis and intestinal lengthening can be achieved using novel IES devices without the risk of mechanical failure. The findings of this study ex-vivo specimens need further corroboration in vivo for long term outcomes.

AMA Research Challenge 2022

Efficiency of IES device in facilitating distraction enterogenesis for treating short gut syndrome.

Abstract Title: Efficiency of IES device in facilitating distraction enterogenesis for treating short gut syndrome.

Background
Short gut syndrome (SGS) is intestinal failure because of inadequate intestinal length often encountered by pediatric surgeons. In SGS, gut adaptation and enteral absorption is low, often requiring long term parenteral nutrition for adequate development. This poses increased risk for complications including line sepsis, necrotizing enterocolitis, and liver failure. Surgical options like small bowel implantation pose significant risks and often provide limited gut expansion. We aim to experimentally evaluate the efficiency of the intestinal expansion sleeve (IES) in determining lengthening of the native bowel. We hypothesize that intestinal expansion commensurate to the IES compression can be achieved already at time of surgery.

Methods
IES devices were made using proprietary cylindrical material with helicoid trusses and isometric ends measuring 30mm in length. Ends of the device were coated with a barium-sealant mixture preventing distress and improved visualization after placement. IES devices were pre-contracted over a dilator, leading to diametric expansion. Mechanical characterization of IES devices and native small intestine segments were performed using an Instron 8874 Biaxial servo hydraulic fatigue testing system. IES devices were implanted in ex vivo intestinal segments of Sprague Dawley rats. Post-deployment gut expansion was measured using calipers. Lastly, histological analysis of the gut tissue was performed for native and experimental tissue following IES removal.

Results
IES devices deployed in rat small intestine immediately produced lengthening of 2.17 ± .17cm to 2.75 ± .22cm (p<.001, n=11). Mechanical characterization demonstrated IES exerted longitudinal forces of 0.13 ± 0.01 N to 0.22 ± 0.01 N upon expansion to post deployment length. Mechanical characterization of native small bowel demonstrated that forces greater than 1.88 ± .21 N produced rupturing of the tissue. The data proves IES devices provide significant expansion without risk of small intestinal failure. Histological examination showed significantly decreased thickness of serosal, muscular, and mucosal layers of the small intestine. 

Conclusion
This study shows that distraction enterogenesis and intestinal lengthening can be achieved using novel IES devices without the risk of mechanical failure. The findings of this study ex-vivo specimens need further corroboration in vivo for long term outcomes.

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Ricardo Correa, MD, EdD
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Charles Lopresto, DO

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Background: This study identifies factors associated with an extended hospital length of stay (LOS), exceeding the Center for Medicare and Medicaid Services (CMS) predicted LOS in pediatric transplant patients, based off of patients’ actual coded diagnostic related group (DRG) by hospital billing. DRG codes are not specific to pediatric patients. 

Methods: We conducted a retrospective chart review of 45 patients who received a solid organ transplant at a single academic pediatric hospital between January 2018- December 2021. All patients who underwent transplant surgeries were included regardless of the outcome. Clinical data was collected and analyzed.

Results: The average age was 10 years, 64% male and 44% white. Of the 45 patients, 27 were kidney recipients, 12 heart, and 6 liver. 81%(n=21) of kidney, 75%(n=9) of heart, and 67%(n=4) of liver transplant patients were noted to have exceeded their predicted LOS. The average number of exceeded days was 2.1 for kidney, 104.8 for heart, and 16.6 for liver recipients. 
Factors associated with exceeding LOS in kidney transplant patients included longer operative time (262.9-vs-220.6minutes,(p=0.01)) and greater warm ischemia time (42.1-vs-31.4minutes,(p=0.00)), cold ischemia time was not significantly different. Protective factors for discharge within the predicted timeframe included early transplantation from the time of admission (0-vs-0.27days after admission, (p=0.005)) and live organ transplantation (60%-vs-9%,(p=0.01)). However the relative significance of these factors may be influenced by possible discrepancies in hospital coding. 36.4% of kidney transplant patients who exceeded LOS were on hemodialysis with 31.8% on peritoneal dialysis however only 4.6% received the DRG code Kidney transplant with hemodialysis. DRG codes with hemodialysis have longer expected LOS than without.
Patients who underwent heart and liver transplantation showed minimal significant differences across the analyzed factors, likely due to the limited number of patients who underwent these procedures at our institution. 

Conclusion: Most solid organ transplant patients, regardless of organ transplanted, where noted to have exceeded the expected LOS for their procedure according to CMS billing. Clinical data from these patients’ hospital stay can be utilized to mitigate factors associated with exceeding LOS and should be used to adjust CMS LOS predictions to be specific for pediatric patients.

Factors Impacting Length of Hospital Stay in Pediatric Transplant Patients

Mucoepidermoid Carcinoma (MEC) in Remission with Gefitinib

Background: Acute cholecystitis is commonly treated with laparoscopic cholecystectomy, if feasible. However, critically ill patients can be managed with a percutaneous cholecystostomy tube (PCT) for biliary drainage. This is a temporizing measure and does not represent a final treatment. We aimed to compare the outcomes of performing an interval cholecystectomy vs. conservative management after PCT placement. 
Methods: We conducted a retrospective study of all patients with a PCT placed for acute calculous cholecystitis (ACC) at a single center from October 2010-March 2015. 
Results: Ninety-five patients (median age 79 years) underwent PCT placement for ACC. Only 26.3% of patients underwent interval cholecystectomy. The mortality rate within 6 weeks of ACC diagnosis was higher in the non-surgical group but this was not statistically significant. The number of re-admissions and complications of biliary disease was higher in the surgical group before undergoing interval cholecystectomy, specifically, choledocholithiasis (44% vs. 21.4%; p=0.03). Patients who had an ICU admission [ OR 0.21; 95% CI 0.07-0.66] or increased age [OR 0.94; 95% CI 0.89-0.98] were less likely to undergo interval cholecystectomy. Nine cholecystectomies were performed laparoscopic, 6 were converted to open and 10 were done in an open fashion. The complication rate in the first 30 days after cholecystectomy was 56%. Most complications occurred when surgery was performed in an open or converted to open technique (11/14=78.6%) vs. laparoscopic (3/14=21.4%).
Conclusion: The relatively high incidence of biliary complications in the period between PCT placement and cholecystectomy calls for timely cholecystectomy in patients treated with PCT. When feasible, patients with a history of ACC should undergo interval cholecystectomy. 


What happens after percutaneous cholecystostomy tube for acute calculous cholecystitis?

Background: Targeted radionuclide therapy (TRT) is an emerging treatment for metastatic disease that delivers systemic radiation via a therapeutic radionuclide-linked, tumor-targeting vector. We have previously shown that low dose radiation delivery with 90Y-NM600 improves tumor response to immune checkpoint inhibitors (ICIs). NM600 is selectively taken up and retained in murine and human tumors. Understanding the effect of different radionuclide physical properties (emission type, linear energy transfer (LET), half-life, and tissue range) on immunomodulation of immunologically cold cancers can improve clinical treatment and avoid immunosuppression encountered with systemic external beam radiation therapy (EBRT). Here, we study 90Y, 177Lu, and 225Ac in immunologically cold syngeneic murine tumor models, MOC2 head and neck squamous cell carcinoma and B78 melanoma, monitoring cGAS/STING mediated type 1 interferon (IFN1) responses. We hypothesized that the radionuclide’s physical properties would differentially impact immunomodulation.
Methods: 90Y, 177Lu, or 225Ac were added to culture media in activities estimated by the Medical Internal Radiation Dose method to deliver 12 Gy (MOC2) or 4 Gy (B78) to the cell monolayer by an infinite timepoint. qPCR was performed on cDNA from cells that were irradiated with EBRT, 90Y, 177Lu, or 225Ac, and harvested on days 1, 3, or 7. Mice bearing B78 WT or Tmem173 -/- CRISPR deletion B78 (STING KO) tumors were randomized to receive 1.5 Gy EBRT, an equivalent tumor dose of 90Y- or 177Lu-NM600 determined by the Monte Carlo-based RAPID platform, 0.5 μCi 225Ac-NM600, or no radiation on day 1. Tumors were harvested on days 4, 7, and 10 for RT-qPCR.
Results: Expression of immune susceptibility markers (Mhc1, Pdl1) and IFN1 response- associated genes (Ifnβ1, Mx1) was upregulated in MOC2 and B78 cells following EBRT/TRT, compared to controls. The timing and magnitude of these effects correlated with radionuclide half-life and LET. 
Conclusion: These studies show the capacity to deliver immunomodulatory radiation to tumors using γ-, β- or α-emitting TRT. Understanding TRT effects on the tumor microenvironment may pave integration of TRT and immunotherapies into clinical care to enhance anti-tumor immunity.

90Y-, 177Lu-, and 225Ac-NM600 dose rate effect on immune response in murine tumor models 

Background: Head and neck squamous cell carcinoma (HNSCC) is the most common cancer of its anatomical region. Cisplatin-based therapies are the gold standard of treatment for both HPV- associated and non-HPV-associated etiologies. The treatment regimen includes either 3 weeks of high-dose cisplatin or 6 weeks of low-dose cisplatin, both with concurrent radiation. Malnutrition, secondary to decreased swallowing function, poses a significant challenge to HNSCC treatment. Swallowing function is a significant marker for prognosis and outcome of patients being treated for HNSCC, but the effects of cisplatin dosage on swallowing function have not been studied. The present study sought to understand how each cisplatin regimen affected swallowing function.
Methods: A cohort of 237 patients who were treated for HNSCC at the University of South Dakota Sanford Medical Center in Sioux Falls, SD, between 2010 and 2019 were studied via retrospective electronic medical record review; 109 received high-dose and 128 received low- dose cisplatin. Gastrostomy tube dependence at various timepoints was used as the primary endpoint given that it serves as a proxy for swallowing function. Secondary endpoints included weight changes, esophageal stricture, lymphedema, hospital admission, and overall
survival. Descriptive statistics were used to summarize demographics and treatment variables. Bivariate associations between independent and dependent variables were analyzed. Chi-square tests were used for categorical variables and t-tests for continuous variables. Statistical tests were two-tailed and the significance level set at p <0.05.
Results: Both the primary and secondary outcomes were not statistically significant.
Ototoxicity and renal toxicity were significantly higher in the high-dose group. Ototoxity overall was significantly higher (p=0.0005), with audiology testing and referral for hearing aids both being significantly higher (p<0.001 and 0.0003, respectively). Renal toxicity was significantly higher at the 30-day and 1-year post-treatment timepoints (p=0.0005 and p=0.02, respectively).
Conclusion: This study suggests that swallowing function is not different in patients receiving high vs. low dose cisplatin for HNSCC treatment. Although the significant data on ototoxicty and nephrotoxicity supports already established conclusions regarding the toxicity of high-dose cisplatin, it strengthens our lack of statistical significance in the primary and secondary endpoints.

Assessment of Swallowing Function in Patients with Head and Neck Squamous Cell Carcinoma in High vs. Low Dose Cisplatin

Background: Historically, central nervous system (CNS) involvement in the setting of acute myeloid leukemia (AML) was identified on the basis of symptoms, including headaches, cranial nerve deficits, and mental status changes. In recent years, screening recommendations have been developed to include FLT3 gene mutations, monocytic features, hyperleukocytosis, and CNS symptoms. However, the incidence, prognosis, and optimal treatment strategy are not well described.

Methods: This study was conducted through a retrospective electronic medical record review at the University of Kansas Medical Center from years 2015-2020. The inclusion criteria were AML patients who received a diagnostic lumbar puncture. Data included the overall incidence of CNS involvement among adult AML patients, AML characteristics associated with CNS involvement, and number of intrathecal treatment doses required for CNS clearance. The protocol was approved by the University of Kansas Medical Center Human Subjects Committee. 

Results: Forty-eight patients met our inclusion criteria; 25 were CNS-positive and 23 were CNS-negative (overall screening detection rate of 52%). The incidence of CNS involvement among only newly diagnosed AML patients was 3.24%. Indications for lumbar puncture included 26 patients with CNS symptoms, 24 with a monocytic phenotype, 16 with the FLT3 mutation, and 14 with hyperleukocytosis, with many having more than one characteristic concerning for CNS involvement. Screening detection rates were 58% for patients with 3 characteristics suggestive of CNS involvement, 60% for 2 characteristics, 45% for CNS symptoms, and 30% for monocytic phenotype. The CNS-positive group consisted of 28% with 3 characteristics, 24% with 2 characteristics, 20% with CNS symptoms, 12% with monocytic phenotype, 4% with FLT3 mutation, and 4% with hyperleukocytosis. Seventy-two percent of the CNS-positive group achieved confirmed CNS clearance with 72% of those patients only requiring 1 or 2 doses of intrathecal chemotherapy.

Conclusion: This data indicates that current screening guidelines appear to properly identify a patient population at risk for CNS involvement. Due to the diverse patient presentations in this analysis, these results also emphasize the need for ongoing research to further delineate risk factors for CNS involvement in AML. Improved identification of risk factors will likely lead to earlier detection and improved patient outcomes.

Central Nervous System Involvement in Adult Acute Myeloid Leukemia Patients

Abstract Title: Characterization of Natural Killer and Cytotoxic T Cell Immune Infiltrates in Pancreatic Ductal Adenocarcinoma

Background: Pancreatic ductal adenocarcinoma (PDAC) is characterized by a poor prognosis and resistance to systemic therapies including immunotherapy. Although PDAC has been linked to low T cell infiltrate, the contribution of natural killer (NK) cells has received less attention. Our objective was to evaluate the immune parameters PDAC, including markers of NK cells, to determine if NK cells associate with patient outcomes. 

Methods: We analyzed tumors from 93 PDAC patients treated from 2012 – 2020. Predictor variables included tumor infiltrating lymphocytes (TILs), T cell markers (CD3+, CD8+, CD45RO+), NK markers (NKp46) and NK inhibitory markers (TIGIT and MHC-I). TILs were scored from 0-3, and immune markers were scored from 0-300. We also evaluated neutrophil and lymphocyte levels in the blood. Primary outcome variables were metastasis-free survival (MFS) and overall survival (OS), analyzed by the Kaplan-Meier method. 


Results: Mean age was 70, 55% were female, and the mean tumor size was 3.1±1.1cm. 89% involved the pancreatic head, and 63% were lymph node positive. The majority of patients received adjuvant therapy. With a median follow up of 24 months, median survival was 35 months. Blood lymphocytes levels prior to surgery were positively correlated with TILs (p=0.008 r=0.3). Median TILs infiltration was 1.1, and 50% were 0 or 1. Mean CD3+ score was 20.6±1, and mean NKp46 was 3.1±3.9. Although there was slight positive correlation between T cell and NK cell scores (CD3+/NKp46 p=0.005, r=0.3; CD8+/NKp46 p=0.05, r=0.2), neither T nor NK cell infiltration was associated with MFS or OS. Similarly, there was a tight positive correlation between MHC-I expression and all T cell markers (CD3+, CD8+ and CD45RO+), but not with NKp46 nor with survival outcomes (MFS/OS, P>0.05). TIGIT expression was also low (mean 30.8±21.9).

Conclusion: NK and T cell infiltrates are overall low in PDAC and do not associate with oncologic outcomes. Further characterization of the immune infiltrate in PDAC, including inhibitory signals and suppressive cell types, may yield better biomarkers of prognosis and immune targeting in this refractory disease.


Characterization of Natural Killer and Cytotoxic T Cell Immune Infiltrates in Pancreatic Ductal Adenocarcinoma

Introduction: BTEX (benzene, toluene, ethylbenzene, and xylene) is well known for its toxicity via environmental, occupational, and recreational exposures. We aim to study the association of socioeconomic disparity and cancer amongst individuals with exposure of BTEX.
Methods: A retrospective cross-sectional study was performed between 2013 and 2018 utilizing the NHANES database. Adult individuals having data on socio-demographic questionnaires and lab findings on exposure to BTEX were included. Prevalence of cancer was identified amongst exposure to BTEX (vs no-BTEX). Univariate (chi-square test and Mann-Whitney U test) and Multivariate (survey logistic regression) analysis was performed to evaluate the epidemiologic characteristics of individuals exposed to BTEX and association of cancer with BTEX exposure in comparison to no BTEX exposure. The p value of 0.05 considered statistically significant.
Results: 124,162 participants were identified with BTEX exposure. Individuals with BTEX exposure were young (49 vs 51-year-old), male (91% vs female: 87%), and Mexican American (92% vs Non-Hispanic Black: 89% vs Non-Hispanic White: 89% vs other Hispanic: 87%). (p<0.0001) Univariate analysis showed higher total prevalence of cancer in BTEX (9.3% vs. 1.3%; p<0.0001) compared to no BTEX. Individuals with BTEX exposure had higher prevalence of blood cancer (0.47% vs 0.00; p<0.0001), leukemia (0.56% vs 0.00; p<0.0001), and lymphoma (1.72% vs 0.39%; p<0.0001) in comparison with no exposure. Multivariate analysis showed participants with BTEX exposure had 10% higher risk of cancer (aOR: 1.10, 95%CI: 1.10-1.10; p<0.0001) compared to no BTEX exposure. Additionally, age (1.07, 1.07-1.07- with increment in 10 years; p<0.0001), Non-Hispanic White (4.79, 4.79-4.80; p<0.0001), Hispanics (2.49, 2.49-2.50; p<0.0001), and Non-Hispanic Black (2.21, 2.21-2.22; p<0.0001) were associated with higher odds of BTEX exposure-associated cancer. (c=0.82) 
Conclusion: Age, race, gender, and income were highly associated with BTEX exposure. Future studies are warranted to evaluate the association of the risk of BTEX-related cancer with sociodemographic disparities.

Demographic disparities and risk of cancer amongst the United States population with exposure to BTEX (benzene, toluene, ethylbenzene, and xylene) - a cross-sectional study

Background
Numerous studies have attempted to construct cell classifiers based on machine learning in recent years. The following project examines the feasibility of building deep learning models to accurately distinguish cells that are nearly morphologically indistinguishable. The dataset used in the project is the International Symposium on Biomedical Imaging (ISBI) 2019 C-NMC dataset. The image repository was released to the public as part of a global machine learning competition that culminated in a symposium where the best performing models were presented. The cells were collected through bone marrow biopsies from 69 patients suffering from ALL and 49 healthy patients . Lymphoblasts within this dataset were digitally isolated and displayed on a black background.

Methods
Three different neural network models were created: a simple Logistic Regression model, a Convolutional Neural Network (CNN), and a ResNet50V2 neural network. To yield better results, simple adjustments to standard neural network parameters were implemented. The original dataset was imbalanced, so weights were applied to balance the dataset. Transformations, such as mirroring and rotation, were incorporated to increase the size of the dataset, which was necessary to address the limited dataset size. 

Results
The results of these models were promising with the highest performing model, CNN, accomplishing an accuracy score of 75%.

Conclusion
Ultimately, this branch of research is worth exploring further. Tuning parameters during model construction directly resulted in accuracy improvements. This has been proven in other studies used on the same dataset, which were able to accomplish higher accuracy scores based on different tuning methodologies.

Diagnosing Acute Lymphoblastic Leukemia with Machine Learning


Introduction: Lung adenocarcinoma is the most prevalent non-small cell lung cancer. Up to 15% of lung adenocarcinomas are characterized by mutations in the epidermal growth factor receptor (EGFR) gene. Osimertinib, an EGFR tyrosine kinase inhibitor, is an effective method of treatment in EGFR-mutant lung cancer. However, osimertinib resistance is frequent. The mechanisms of Osimertinib are heterogenous but here we describe a new case of osimertinib resistant carcinosarcoma. 
Case history: A 63-year-old woman presented with headaches, right arm weakness, and gait instability. Radiographic evaluation showed a left parietal lobe mass, enlarged hilar lymph nodes, and numerous lung nodules. CT-guided biopsy of one lung nodule revealed an invasive adenocarcinoma which expressed TTF-1 but was negative for p-40 immunostaining. Tumor next generation sequencing revealed a rare exon 19 EGFR (E747_A750del) deletion. The patient was treated with stereotactic radiosurgery for brain metastasis followed by osimertinib immunotherapy. More than a year later, lead to a recurrence of the patient’s symptoms. Repeat radiographic evaluation showed new mediastinal lymphadenopathy. Fine needle aspiration of the enlarged mediastinal lymph nodes revealed carcinosarcoma with minimal adenocarcinoma component. A repeat tumor next generation sequencing confirmed the same EGFR exon 19 deletion (E746_A750del) in addition to TP53/Rb mutation and a high tumor mutational burden. 
Conclusion: This case demonstrates another association of osmertinib resistance in pulmonary adenocarcinoma with a specific EGFR mutation. This case is unique as it also documents histologic transformation of EGFR-mutated lung adenocarcinoma into a carcinosarcoma as a possible underlying mechanism of osimertinib resistance. 


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Factors Impacting Length of Hospital Stay in Pediatric Transplant Patients

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