Determining the Effect of KmtR Mutants, E101Q, H102Q, and H111Q on the Metal Binding Affinities

Mycobacterium tuberculosis is the second leading infectious killer after COVID-19. The bacteria utilizes several metal transport systems to help it survive in the host.With an increase in the number of multiresistant, extensively resistant and totally drug-resistant strains, the development of new therapeutic strategies that target other essential pathways in the bacteria is critical. The bacteria contain several metal transport systems which are necessary for its survival. Additionally, the bacteria has two metalloregulators that are associated with nickel and cobalt export, NmtR and KmtR. The focus of this research is on KmtR, which represses the expression of the genes, cdf (which encodes the export protein) and kmtR. The goal of our research is to identify the residues that are responsible for binding the cognate metals, nickel and cobalt, as well as the noncognate metal, zinc, to KmtR. Mutagenesis studies coupled with metal binding experiments will be used to determine how KmtR binds these metals. The E101Q, H102Q, and H111Q mutants, among others, have been made, expressed, and purified in our lab. Data obtained from Isothermal Titration Calorimetry determined that all three mutant proteins bind cobalt with nanomolar affinities and the H111Q mutant KmtR proteins binds cobalt an order of magnitude weaker than the other two mutant proteins. Research reported as supported fully by the RI Institutional Development Award (IDeA) Network for Biomedical Research Excellence (RI-INBRE) from the National Institute of General Medical Sciences of the National Institutes of Health under grant #P20GM103430.Copyright © 2023 The American Society for Biochemistry and Molecular Biology, Inc.

Impact of the COVID-19 Pandemic on Radiation Oncology Consult Volumes Within a Multi-Site Academic Practice

Purpose/Objective(s): Cancer care has been significantly impacted by the COVID 19 pandemic;however, a comprehensive understanding of the downstream effects of the pandemic on radiation oncology practice in the United States has not been well quantified. We sought to quantify the differences in radiation consult volumes across varying disease sites and practice locations within our National Cancer Institute (NCI) designated Comprehensive Cancer Center, at time points preceding and during the COVID 19 pandemic. The purpose of this study is to identify potential gaps in care for specific disease sites that could addressed in the future. Materials/Methods: We collected new patient referral data from three clinical radiation oncology sites for the 2019 calendar year and the 2020 calendar year. Overall new patient referrals for 2019 and 2020 were analyzed and compared as well as consult volume for each disease site. Results: In 2019, there was a total 4,284 overall consults and in 2020 there was a total of 3,442 consults. This is a 20% reduction in consults over a 12-month period. The month of April had the most significant decrease in consults with a total of 357 consults in April 2019 compared to a total of 179 consults in April 2020 (50% reduction). The month of February had the least reduction with 329 total consults in 2019 compared to a total of 313 consults in 2020 (5% reduction). There was a decrease in consult volumes for all tumor sites with the exception of following tumor sites which saw an increase in consult volumes: colon (55.6%), kidney &renal pelvis (15.8), larynx (32.7%), oral cavity (7%), Non-Hodgkin's Lymphoma (9.9%), other head & neck (13.9%), and thyroid cancer (36.4%). Breast and prostate cancer had the greatest absolute change in consult volume loss (32.6%, 29.3% respectively). Oral tongue cancer was the sole tumor site that had no change in consult volume across the study period. Conclusion: The ramifications of COVID-19 will be seen in the practices of clinicians, cancer centers, and the experiences of patients and their families for years to come. We found a 20% overall reduction in new patient referrals for 2020. The most significant absolute change in volume loss was seen in breast and prostate cancer. Head and neck cancer referrals were the most minimally impacted, with some increases in referrals during the study period which could possibly be related to limited surgical resources necessitating non-operative treatment. Further studies are needed to more comprehensively understand the impact of the COVID 19 pandemic on radiation oncology practice.

NRG Oncology/Alliance LU005: A Phase II/III Randomized Study of Chemoradiation vs. Chemoradiation Plus Atezolizumab in Limited Stage Small Cell Lung Cancer

Clinical outcomes for limited stage small cell lung cancer (LS-SCLC) remain suboptimal. Standard of care chemoradiation with platinum/etoposide and thoracic radiation to 45 Gy delivered twice daily followed by prophylactic cranial irradiation yields a median overall survival of 30 months. LU005 is a randomized phase II/III trial designed to test the addition of atezolizumab to concurrent chemoradiation. Patients with LS-SCLC (Tx-T4, N0-N3, M0) are randomly assigned in a 1:1 ratio to either standard chemoradiation, consisting of thoracic radiation (45 Gy twice daily or 66 Gy daily) with concurrent platinum/etoposide chemotherapy, or the experimental arm, consisting of the same chemoradiation regimen plus the addition of atezolizumab delivered concurrently with thoracic radiation, every 3 weeks for 12 months duration. Thoracic radiation begins with the second cycle of chemotherapy in both treatment arms. Stratification variables include radiation schedule (once daily vs. twice daily), chemotherapy (cisplatin vs. carboplatin), gender, and performance status (PS 0/1 vs. 2). Prophylactic cranial radiation is recommended for patients who have a response to treatment. The phase II primary endpoint is progression free survival (PFS) and the phase III primary endpoint is overall survival (OS). The overall sample size for phase II/III will be 506. Secondary endpoints include objective response rates, local control, distant metastases free, and quality of life. Correlative studies will include blood and tissue based tumor mutational burden analysis, with the hypothesis that higher mutational burden will predict for improved PFS in the experimental arm. As of 3/01/2021, 374 sites are approved to enroll patients. Two-hundred patients have been accrued. Current enrollment is ahead of projected accrual. LU005 is a randomized II/III trial testing the addition of atezolizumab to standard chemoradiation for LS-SCLC. Accrual remains robust in spite of the ongoing COVID 19 pandemic. Funding: This project was supported by grants U10CA180868 (NRG Oncology Operations), U10CA180822 (NRG Oncology SDMC), U24CA180803 (IROC) from the National Cancer Institute (NCI) and Genentech. [ABSTRACT FROM AUTHOR] Copyright of International Journal of Radiation Oncology, Biology, Physics is the property of Pergamon Press - An Imprint of Elsevier Science and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Rapid implementation of a virtual inpatient diabetes service (VIDS) during the COVID-19 pandemic

Background: In response to the COVID-19 pandemic, UHL rapidly implemented a daily (Monday-Friday) VIDS running from 23/03/20 to 03/08/20. All inpatients with diabetes (including COVID-19 positive) were reviewed virtually. During the pandemic, the numbers of inpatients with diabetes fell from on average >300 (pre-pandemic) to approximately 200 each day. The peak of UHL inpatients with COVID-19 (April 2020) was 204 patients. Aims: The aims of the study were as follows: (1) to review all patients with diabetes ±COVID-19;(2) to minimise exposure of staff to COVID-19;(3) to preserve PPE for frontline staff;and (4) evidence safe levels of care. Results: All patients: % CBG <2.9 mmol/L was 0.7, 0.9 and 0.9;4-12 mmol/L was 75.0, 76.5 and 76.0;>25.0 mmol/L was 0.9, 0.8 and 0.8 pre, during and post VIDs. Patients with CFS 5 or above: % CBG <2.9 mmol/L was 0.8, 0.8 and 0.7;4-15 mmol/L (range extended for older frail inpatients) was 84.8, 87.5 and 85.6;>25.0 mmol/L was 1.2, 0.7 and 0.8 pre, during and post VIDs. NaDIA harms: no rise in hypo harms during VIDs. Two cases of in-hospital DKA were identified by VIDS team (3 DKA harms reported), one case: COVID-19 positive taking SGLT2i. Discussion: Introduction of a VIDS did not lead to detrimental outcomes in terms of in-hospital harms. A small increase in % CBG <2.9 mmol/L for all patients was not associated with a rise in NaDIA hypo harms. If we need to reinstate a VIDS during a second COVID-19 wave, we can be reassured re safety and should focus on minimising risk of hypoglycaemia, appropriate targets for individual patients (eg, older/frail/EoL patients) and risk of DKA with COVID-19/SGLT2i and national guidance for management of inpatients with diabetes and COVID-19.

Glycaemic control in covid-19 patients in an intensive care unit (ICU) setting

Background: We aim to examine the prevalence and management of hyperglycaemia in non-diabetic and diabetic ICU patients with covid-19. Methods: Retrospective study of 27 ICU patients with covid- 19 treated with dexamethasone. Results: Mean age 58yrs and 74% male: 26% female. Prevalence of pre-existing diabetes was 44% (12) while 56% (15) had no known history of diabetes. Type 2 diabetes accounted for all cases of pre-existing diabetes. In preceding 6 months 67% had no HbA1c check and 11.1% had an HbA1c on admission (all people with known diabetes). Ninety-three percent became hyperglycaemic (glucose >12 mmol/l) while in ICU. Mean peak glucose throughout admission for patients with pre-existing diabetes and those with no prior history were 18.5 mmol/l and 15.1 mmol/l, respectively. Of those with hyperglycaemia, 76% received insulin treatment: 92% of patients with pre-existing diabetes had some form of insulin treatment compared to 53% of patients with no prior history. Treatment regimens: actrapid infusion (73.7%), actrapid infusion with long-acting insulin (15.8%) and novorapid as required doses (10.5%). A third of patients required input from the diabetes team while on ICU. Conclusion: Our data shows that the majority of covid-19 patients treated with dexamethasone, regardless of diabetes history, develop hyperglycaemia and subsequently require insulin. HbA1c is not routinely performed on admission onto intensive care;however it is a useful tool in detecting undiagnosed diabetes at presentation, assessment of prior glycaemic control and degree of insulin resistance in patients with known diabetes. HbA1c measurement has implications for appropriate on-going management and long-term specialist input/follow-up.

Snapshot audit of glucose monitoring for people with covid-19 recently started on dexamethasone (including people with diabetes (PWD) and without diabetes (PWOD))

Aims: Snapshot audit of initial glucose monitoring for above group of patients against National guidance for glucose monitoring/ management for covid-19 treated with dexamethasone published in 2020. Methods: Review of single day's dexamethasone prescription report (N = 17). Data collected from electronic hospital systems. Results: Mean age 66(28-93 yrs);female:male, 10:7;47% frail, 35% PWD (type 2 diabetes);88% medical ward, 12% HDU. Ninety-four percent had glucose check within 24 hrs of admission. One patient had no glucose check (admission or thereafter). Mean glucose on admission-8.5 mmol/l (12.0 mmol/l PWD : 6.5 mmol/l PWOD). Blood ketone level checked in one patient on admission (glucose-15 mmol/l), diabetic ketoacidosis(DKA) confirmed. Ongoing monitoring appropriate in 35% (50% PWD: 27% PWOD). No patients had HbA1c check in hospital. HbA1c: average 11 months prior to admission (8 months PWD: 15 months PWOD). Patients ranged, day 1-day 4 of dexamethasone treatment. Of PWD, 3 tablet treatment only;3 insulin only. Three required no adjustment to diabetes medication, two patients (DKA;acutely unwell) required intravenous insulin;one gliclazide increased (refused insulin). Three PWOD not given corrective insulin doses when glucose >12.0 mmol/l;not indicated in remaining patients (except PWD who refused insulin). Conclusion: Despite 94% patients having admission glucose checked, on-going early monitoring was poor and no admission HbA1c checked. Prompt and regular monitoring is critical in identifying hyperglycaemia/decompensation/DKA and allowing timely treatment. Non-specialist teams need to familiarise with guidance, diabetes teams should pro-actively in-reach to clinical areas and all should have a low threshold for excluding diabetes emergencies.

Guidelines for the management of diabetes in care homes during the Covid-19 pandemic.

The National Diabetes Stakeholders Covid-19 Response Group was formed in early April 2020 as a rapid action by the Joint British Diabetes Societies for Inpatient Care, Diabetes UK, the Association of British Clinical Diabetologists, and Diabetes Frail to address and support the special needs of residents with diabetes in UK care homes during Covid-19. It was obvious that the care home sector was becoming a second wave of Covid-19 infection and that those with diabetes residing in care homes were at increased risk not only of susceptibility to infection but also to poorer outcomes. Its key purposes included minimising the morbidity and mortality associated with Covid-19 and assisting care staff to identify those residents with diabetes at highest risk of Covid-19 infection. The guidance was particularly created for care home managers, other care home staff, and specialist and non-specialist community nursing teams. The guidance covers the management of hyperglycaemia by discussion of various clinical scenarios that could arise, the management of hypoglycaemia, foot care and end of life care. In addition, it outlines the conditions where hospital admission is required. The guidance should be regarded as interim and will be updated as further medical and scientific evidence becomes available.

Guidelines for the management of diabetes services and patients during the COVID-19 pandemic.

The UK National Diabetes Inpatient COVID Response Group was formed at the end of March 2020 to support the provision of diabetes inpatient care during the COVID pandemic. It was formed in response to two emerging needs. First to ensure that basic diabetes services are secured and maintained at a time when there was a call for re-deployment to support the need for general medical expertise across secondary care services. The second was to provide simple safe diabetes guidelines for use by specialists and non-specialists treating inpatients with or suspected of COVID-19 infection. To date the group, comprising UK-based specialists in diabetes, pharmacy and psychology, have produced two sets of guidelines which will be continually revised as new evidence emerges. It is supported by Diabetes UK, the Association of British Clinical Diabetologists and NHS England.