Quantitative Proteomics and Metabolomics of Culture Medium from Single Human Embryo Reveal Embryo Quality-Related Multiomics Biomarkers.

An effective tool to assess embryo quality in the assisted reproduction clinical practice will enhance successful implantation rates and mitigate high risks of multiple pregnancies. Potential biomarkers secreted into culture medium (CM) during embryo development enable rapid and noninvasive methods of assessing embryo quality. However, small volumes, low biomolecule concentrations, and impurity interference collectively preclude the identification of quality-related biomarkers in single blastocyst CM. Here, we developed a noninvasive trace multiomics approach to screen for potential markers in individual human blastocyst CM. We collected 84 CM samples and divided them into high-quality (HQ) and low-quality (LQ) groups. We evaluated the differentially expressed proteins (DEPs) and metabolites (DEMs) in HQ and LQ CM. A total of 504 proteins and 189 metabolites were detected in individual blastocyst CM. Moreover, 9 DEPs and 32 DEMs were identified in different quality embryo CM. We also categorized HQ embryos into positive implantation (PI) and negative implantation (NI) groups based on ultrasound findings on day 28. We identified 41 DEPs and 4 DEMs associated with clinical implantation outcomes in morphologically HQ embryos using a multiomics analysis approach. This study provides a noninvasive multiomics analysis technique and identifies potential biomarkers for clinical embryo developmental quality assessment.

Controlling Phase in Colloidal Synthesis.

A fundamental precept of chemistry is that properties are manifestations of the elements present and their arrangement in space. Controlling the arrangement of atoms in nanocrystals is not well understood in nanocrystal synthesis, especially in the transition metal chalcogenides and pnictides, which have rich phase spaces. This Perspective will cover some of the recent advances and current challenges. The perspective includes introductions to challenges particular to chalcogenide and pnictide chemistry, the often-convoluted roles of bond dissociation energies and mechanisms by which precursors break down, using very organized methods to map the synthetic phase space, a discussion of polytype control, and challenges in characterization, especially for solving novel structures on the nanoscale and time-resolved studies.

The Effect of Interprofessional Education on Student Readiness for Collaborative Practice.

BACKGROUND: Health care reform promotes interprofessional patient-centric health care models associated with improved population health outcomes. Interprofessional education (IPE) programs are necessary to cultivate collaborative care, yet little evidence exists to support IPE pedagogy within nursing and other health science academia. METHOD: This quasiexperimental study examined differences in pre- and posttest Readiness for Interprofessional Learning Scale (RIPLS) scores following an IPE intervention. The IPE intervention consisted of a video presentation and a debriefing session after a simulated interprofessional collaborative patient care conference that introduced baccalaureate nursing and health science students to the roles and responsibilities of clinicians in team-based primary care. Pre- and postintervention RIPLS scores were analyzed. RESULTS: Pre- and postintervention RIPLS scores increased across all subscales, with distinct variation between nursing and health science student subscales. CONCLUSION: This IPE intervention had positive effects on students' readiness for interprofessional learning. Additional research is warranted to support health science pedagogy. [J Nurs Educ. 2024;63(5):304-311.].

Environmental plastics in the context of UV radiation, climate change, and the Montreal Protocol.

There are close links between solar UV radiation, climate change, and plastic pollution. UV-driven weathering is a key process leading to the degradation of plastics in the environment but also the formation of potentially harmful plastic fragments such as micro- and nanoplastic particles. Estimates of the environmental persistence of plastic pollution, and the formation of fragments, will need to take in account plastic dispersal around the globe, as well as projected UV radiation levels and climate change factors.

The Impact of Acute Postoperative Pain in Developing Chronic Pain after Total Knee Arthroplasty.

While total knee arthroplasties (TKAs) are performed with the intent to reduce pain, chronic postsurgical pain (CPSP) is one of the most well-documented complications that can occur following surgery. This study aimed to assess whether perioperative factors, focusing on acute postsurgical pain and perioperative opioid consumption, were associated with the development of chronic postsurgical pain. Under general anesthesia, 108 patients underwent TKA and were treated postoperatively with a multimodal analgesia approach. Numeric Rating Scale (NRS) pain scores at rest and with movement were recorded on postoperative days 0-3, 7, 14, and 30. Patients were sent a survey to assess chronic pain at months 22-66, which was examined as a single-group post hoc analysis. Based on the responses, patients were either classified into the CPSP or non-CPSP patient group. Chronic postsurgical pain was defined as an NRS score ≥ 4 with movement and the presence of resting pain. The primary outcome was a change in NRS. There were no differences in NRS pain scores with movement in the first 30 days postoperatively between patients with CPSP and without CPSP. Each unit increase in resting pain on postoperative days 3 and 14 was associated with significantly greater odds of CPSP presence (OR = 1.52; OR = 1.61, respectively), with a trend towards greater odds of CPSP at days 7 and 30 (OR = 1.33; OR = 1.43, respectively). We found that very intense pain in the initial phase seems to be related to the development of CPSP after TKA.

Plastics in the environment in the context of UV radiation, climate change and the Montreal Protocol: UNEP Environmental Effects Assessment Panel, Update 2023.

This Assessment Update by the Environmental Effects Assessment Panel (EEAP) of the United Nations Environment Programme (UNEP) considers the interactive effects of solar UV radiation, global warming, and other weathering factors on plastics. The Assessment illustrates the significance of solar UV radiation in decreasing the durability of plastic materials, degradation of plastic debris, formation of micro- and nanoplastic particles and accompanying leaching of potential toxic compounds. Micro- and nanoplastics have been found in all ecosystems, the atmosphere, and in humans. While the potential biological risks are not yet well-established, the widespread and increasing occurrence of plastic pollution is reason for continuing research and monitoring. Plastic debris persists after its intended life in soils, water bodies and the atmosphere as well as in living organisms. To counteract accumulation of plastics in the environment, the lifetime of novel plastics or plastic alternatives should better match the functional life of products, with eventual breakdown releasing harmless substances to the environment.

Enzymes for dermatological use.

Skin is the ultimate barrier between body and environment and prevents water loss and penetration of pathogens and toxins. Internal and external stressors, such as ultraviolet radiation (UVR), can damage skin integrity and lead to disorders. Therefore, skin health and skin ageing are important concerns and increased research from cosmetic and pharmaceutical sectors aims to improve skin conditions and provide new anti-ageing treatments. Biomolecules, compared to low molecular weight drugs and cosmetic ingredients, can offer high levels of specificity. Topically applied enzymes have been investigated to treat the adverse effects of sunlight, pollution and other external agents. Enzymes, with a diverse range of targets, present potential for dermatological use such as antioxidant enzymes, proteases and repairing enzymes. In this review, we discuss enzymes for dermatological applications and the challenges associated in this growing field.

Synergistic effect of silver nanoparticle-embedded calcite-rich biochar derived from Tamarindus indica bark on 4-nitrophenol reduction.

Calcite-biochar composites are attractive materials with outstanding adsorption capabilities for removing various recalcitrant contaminants in wastewater treatment, however, the complexity of their synthesis limits their practical applications. In this work, we have prepared calcite-rich biochar (Ca-BC) from a single precursor (Tamarindus indica bark), which simplifies the synthetic route for preparing calcite-biochar composite. The as-synthesized composite is utilized to make a heterogeneous catalytic system containing the supported silver nanoparticles (Ag@Ca-BC) formed by the reduction of Ag+ ions on the surface of the composite. The formation of Ag@Ca-BC is confirmed by various characterization techniques such as PXRD, FT-IR, UV-Vis, cyclic voltammetry, impedance measurement, SEM, and TEM analyses. Especially, the TEM analysis confirms the presence of Ag nanoparticles with size ranging between 20 and 50 nm on the surface of Ca-BC composite. The nano-catalyst Ag@Ca-BC efficiently promotes the conversion of 4-nitrophenol to 4-aminophenol using NaBH4 as the reductant in water within 24 minutes at room temperature, suggesting that Ag@Ca-BC can be an efficient catalyst to remove nitroaromatics from the industrial effluents. The straightforward synthesis of Ca-BC from a single precursor along with its utility as a catalytic support presents a compelling proposition for application in the field of materials synthesis, catalysis, and green chemistry.

Evaluation of the Performance of a Card Game to Introduce Students to Interprofessional Collaboration: A Randomized 2-Group Comparison Study.

BACKGROUND: Gamification is an approach that can be used to introduce interprofessional collaboration in nursing and health science. Card games are an effective and convenient way to educate students about clinical professions. PURPOSE: We compared the perception of an experimental group of students who played an educational card game to a control group that played an uninstructive card game. METHODS: College students (n = 148) from nursing and health science majors consented to play a 30-minute card game and complete a 13-item survey. RESULTS: Perceptions of the card game were significantly better for students in the experimental group who played the interprofessional collaboration game than for those in the control group ( t = 10.33, P < .001). Survey subscales were rated significantly higher for respondents who played the interprofessional card game. CONCLUSIONS: The use of an innovative card game teaching strategy significantly increased the perception of interprofessional collaboration among college students.

Human skin CD141+ dendritic cells regulate cutaneous immunity via the neuropeptide urocortin 2.

Skin immune homeostasis is a multi-faceted process where dermal dendritic cells (DDCs) are key in orchestrating responses to environmental stressors. We have previously identified CD141+CD14+ DDCs as a skin-resident immunoregulatory population that is vitamin-D3 (VitD3) inducible from monocyte-derived DCs (moDCs), termed CD141hi VitD3 moDCs. We demonstrate that CD141+ DDCs and CD141hi VitD3 moDCs share key immunological features including cell surface markers, reduced T cell stimulation, IL-10 production, and a common transcriptomic signature. Bioinformatic analysis identified the neuroactive ligand receptor pathway and the neuropeptide, urocortin 2 (UCN2), as a potential immunoregulatory candidate molecule. Incubation with VitD3 upregulated UCN2 in CD141+ DCs and UVB irradiation induced UCN2 in CD141+ DCs in healthy skin in vivo. Notably, CD141+ DDC generation of suppressive Tregs was dependent upon the UCN2 pathway as in vivo administration of UCN2 reversed skin inflammation in humanized mice. We propose the neuropeptide UCN2 as a novel skin DC-derived immunoregulatory mediator with a potential role in UVB and VitD3-dependent skin immune homeostasis.

The adverse consequences of not using sunscreens.

The adverse effects of solar ultraviolet radiation (UVR) on normal skin are well established, especially in those with poorly melanized skin. Clinically, these effects may be classified as acute, such as erythema or chronic such as keratinocyte and melanocyte skin cancers. Apart from skin type genetics, clinical responses to solar UVR are dependent on geophysical (e.g., solar intensity) and behavioural factors. The latter are especially important because they may result in 'solar overload' with unwanted clinical consequences and ever greater burdens to healthcare systems. Correctly used, sunscreens can mitigate the acute and chronic effects of solar UVR exposure. Laboratory studies also show that sunscreens can inhibit the initial molecular and cellular events that are responsible for clinical outcomes. Despite public health campaigns, global trends continue to show increasing incidence of all types of skin cancer. Large-scale epidemiological studies have shown the benefits of sunscreen use in preventing skin cancer, though it is likely that sunscreen use has not been optimal in such studies. It is evident that without substantial changes in sun-seeking behaviour, sunscreen use is a very important part of the defence against the acute and chronic effects of solar exposure. Ideally, sunscreens should be able to provide the level of protection that reduces the risk of skin cancer in susceptible skin types to that observed in heavily melanized skin.

Les effets indésirables des rayons ultraviolets (UVR) du soleil sur une peau saine sont bien établis, en particulier chez les personnes dont la peau est faiblement concentrée en mélanine. Sur le plan clinique, ces effets peuvent être classés comme aigus, comme un érythème, ou chroniques, comme des cancers de la peau kératinocytaires et mélanocytaires. Outre la génétique du type de peau, les réponses cliniques aux UVR du soleil dépendent de facteurs géophysiques (par exemple, intensité du soleil) et comportementaux. Ces réponses sont particulièrement importantes, car elles peuvent entraîner un « trop-plein de soleil ¼ avec des conséquences cliniques indésirables et des charges de plus en plus importantes pour les systèmes de santé. Utilisés correctement, les protections solaires peuvent atténuer les effets aigus et chroniques de l'exposition aux UV du soleil. Des études en laboratoire montrent également que les protections solaires peuvent inhiber les événements moléculaires et cellulaires initiaux, qui sont responsables des effets cliniques. Malgré les campagnes de santé publique, les tendances mondiales continuent de montrer une incidence croissante de tous les types de cancer de la peau. Des études épidémiologiques à grande échelle ont montré les bénéfices de l'utilisation d'une protection solaire dans la prévention du cancer de la peau, même s'il est probable que l'utilisation d'une protection solaire n'a pas été optimale dans ces études. Il est évident que, sans changements substantiels du comportement d'exposition au soleil, l'utilisation d'une protection solaire est un aspect très important de la défense contre les effets aigus et chroniques de l'exposition au soleil. Idéalement, les protections solaires devraient pouvoir offrir aux types de peau sensibles le niveau de protection qui réduit le risque de cancer de la peau observé pour les peaux fortement concentrées en mélanine.

Pre-Existing Audiometric Hearing Loss is a Predictor of Significant Threshold Shift Following Injury During Combat Deployment.

OBJECTIVES: Military personnel are exposed to multiple risk factors for hearing loss, particularly on the battlefield. The objective of this study was to determine whether pre-existing hearing loss predicted hearing threshold shift in male U.S. military personnel following injury during combat deployment. DESIGN: This was a retrospective cohort study with 1573 male military personnel physically injured in Operations Enduring and Iraqi Freedom between 2004 and 2012. Audiograms before and after injury were analyzed and used to calculate significant threshold shift (STS), defined as a 30 dB or greater change in the sum of hearing thresholds at 2000, 3000, and 4000 Hz in either ear on the postinjury audiogram, relative to the same frequencies on the preinjury audiogram. RESULTS: Twenty-five percent (n = 388) of the sample had preinjury hearing loss, which mostly occurred in the higher frequencies (i.e., 4000 and 6000 Hz). The prevalence of postinjury STS ranged from 11.7% to 33.3% as preinjury hearing level moved from better to worse. In multivariable logistic regression, preinjury hearing loss was a predictor of STS, and there was a dose-response relationship between severity of preinjury hearing threshold and postinjury STS, specifically for preinjury hearing levels of 40 to 45 dBHL (odds ratio [OR] = 1.99; 95% confidence interval [CI] = 1.03 to 3.88), 50 to 55 dBHL (OR = 2.33; 95% CI = 1.17 to 4.64), and >55 dBHL (OR = 3.77; 95% CI = 2.25 to 6.34). CONCLUSIONS: These findings suggest that better preinjury hearing provides increased resistance to threshold shift than impaired preinjury hearing. Although STS is calculated using 2000 to 4000 Hz, clinicians must closely attend to the pure-tone response at 6000 Hz and use this test frequency to identify service members at-risk for STS prior to combat deployment.

Time-lapse proteomics unveil constant high exposure of non-antibiotic drug induces synthetic susceptibility towards regular antibiotics.

Antibiotic resistance is a significant threat to the human race, as regular consumption of antibiotics may lead to antibiotic-resistant bacterial strains. Non-antibiotic drugs also have an extensive impact on bacterial strains, where persistent uptake alters the survival mechanisms of bacteria that could lead to cross-resistance towards other antibiotics. Here, we use time-lapse proteomics shift assays to examine Gram-negative (E. coli. O157:H7 and P. aeruginosa) and Gram-positive (E. faecalis and S. aureus) strains of bacteria for short and continuous exposure to the non-antibiotic drug Hydroxychloroquine (HCQ). Proteomic transitions from wild type to HCQ-exposed strains revealed bacterial transitions and their survival adaptabilities, which were different across all strains. In addition to their structural differences, some shared pathways were enriched among Gram-negative and positive strains. We also validated the cross-resistance and sensitivity towards 24 regularly prescribed antibiotics, indicating that long-term exposure to non-antibiotic drugs may induce general proteomics alterations in the bacterial strains, promoting antibiotic resistance. We validated that HCQ exposure renders Gram-negative strains resistant to Β-lactam and susceptible to macrolides and folic acid. In contrast, Gram-positive strains become susceptible to Β-lactam and resistant to aminoglycosides. Exposure to non-antibiotic drugs causes resistance or susceptibility toward other antibiotics, providing clinicians a reason to overcome antibiotic resistance.

Relationship Between Tinnitus and Hearing Outcomes Among US Military Personnel After Blast Injury.

OBJECTIVES: To examine the association between tinnitus and hearing outcomes among US military personnel after blast injury, including any hearing loss, low-frequency hearing loss, high-frequency hearing loss, early warning shift, and significant threshold shift. DESIGN: In this retrospective study, the Blast-Related Auditory Injury Database was queried for male military service members who had audiometric data 2 years before and after blast injury between 2004 and 2012 with no history of hearing loss or tinnitus before injury (n = 1693). Tinnitus was defined by diagnostic codes in electronic health records. Multivariable logistic regression examined the association between tinnitus and hearing outcomes, while adjusting for covariates. RESULTS: Overall, 14.2% (n = 241) of the study sample was diagnosed with tinnitus within 2 years after blast injury. The proportions of all examined hearing outcomes were higher among service members with tinnitus than those without ( p < 0.001). In multivariable analysis, service members with tinnitus had higher adjusted odds of any hearing loss (odds ratio [OR] = 1.72, 95% confidence interval [CI] = 1.20-2.47), low-frequency hearing loss (OR = 2.77, 95% CI = 1.80-4.26), high-frequency hearing loss (OR = 2.15, 95% CI = 1.47-3.16), early warning shift (OR = 1.83, 95% CI = 1.36-2.45), and significant threshold shift (OR = 2.15, 95% CI = 1.60-2.89) compared with service members without tinnitus. CONCLUSIONS: The findings of this study demonstrate that tinnitus diagnosed within 2 years after blast injury is associated with the examined hearing outcomes in US military personnel. Service members with blast injury who subsequently experience tinnitus should receive routine audiometric hearing conservation testing and be carefully examined for poor hearing outcomes by an audiologist.

Hearing Health Outcomes as a Function of Age, Gender, and Diversity.

The United States does not ensure equitable access to hearing health care for all age groups, largely because these services are costly and even unobtainable in some places. Barriers to care are discussed within a context of the social determinants of health, under-representativeness of hearing-care professionals from historically marginalized communities, older adults and age-related hearing loss, and associated health conditions. The MarkeTrak 2022 study generated a sample of 15,138 respondents with information on 43,597 individuals. Data analysis revealed that self-reported hearing difficulty appears to increase with age with a rate of 12.4% for adults 18 years of age and older. A substantial proportion of individuals with hearing difficulty assumed that their problem was age-related, followed by exposure to loud sound and noise. Individuals with hearing difficulty were nearly three to four times more likely to have tinnitus, cognitive problems, and issues with balance and falling than those with no hearing problems. Self-reported hearing difficulty was lower for historically marginalized groups (7%) than for the White population (12%). Recommendations are presented to reduce the burden of hearing difficulty and hearing aid deserts for rural and urban populations.

Decreased occurrence of ketoacidosis and preservation of beta cell function in relatives screened and monitored for type 1 diabetes in Australia and New Zealand.

AIMS: Islet autoantibody screening of infants and young children in the Northern Hemisphere, together with semi-annual metabolic monitoring, is associated with a lower risk of ketoacidosis (DKA) and improved glucose control after diagnosis of clinical (stage 3) type 1 diabetes (T1D). We aimed to determine if similar benefits applied to older Australians and New Zealanders monitored less rigorously. METHODS: DKA occurrence and metabolic control were compared between T1D relatives screened and monitored for T1D and unscreened individuals diagnosed in the general population, ascertained from the Australasian Diabetes Data Network. RESULTS: Between 2005 and 2019, 17,105 relatives (mean (SD) age 15.7 (10.8) years; 52% female) were screened for autoantibodies against insulin, glutamic acid decarboxylase, and insulinoma-associated protein 2. Of these, 652 screened positive to a single and 306 to multiple autoantibody specificities, of whom 201 and 215, respectively, underwent metabolic monitoring. Of 178 relatives diagnosed with stage 3 T1D, 9 (5%) had DKA, 7 of whom had not undertaken metabolic monitoring. The frequency of DKA in the general population was 31%. After correction for age, sex and T1D family history, the frequency of DKA in screened relatives was >80% lower than in the general population. HbA1c and insulin requirements following diagnosis were also lower in screened relatives, consistent with greater beta cell reserve. CONCLUSIONS: T1D autoantibody screening and metabolic monitoring of older children and young adults in Australia and New Zealand, by enabling pre-clinical diagnosis when beta cell reserve is greater, confers protection from DKA. These clinical benefits support ongoing efforts to increase screening activity in the region and should facilitate the application of emerging immunotherapies.

Innovative digital solution supporting sun protection and vitamin D synthesis by using satellite-based monitoring of solar radiation.

Public health campaigns advise minimising UV radiation (UVR) exposure to prevent skin cancer and precancer, e.g. actinic keratosis (AK). A 3-day clinical field study, in Brazil, was performed to evaluate the mobile app Sun4Health® by siHealth Ltd. The app performs real-time monitoring of both erythemal and vitamin D-effective solar radiation doses using satellite data, enabling personalised recommendations on optimal sun exposure time and sunscreen use. When coupled to a wearable device, the app also provides body-site specific recommendations ("3D" version). 59 healthy volunteers were randomised into 3 groups, each given a different app providing: (1) ultraviolet index only (control app), (2) personalised recommendations and sun overexposure alerts (Sun4Health® app), (3) as (2) but connected via Bluetooth to a wearable device to monitor sun exposure in 3D (Sun4Health®-3D app). Participants were offered sunscreens (SPF 30 and 50) to use at their discretion. Erythema, quantified by reflectance spectroscopy, was assessed daily in the mornings and evenings on six body sites. Serum vitamin D (25(OH)D3) was measured before and after the study. Mean increase of erythema (Mexameter® units ± SD) of all exposed body sites combined over 3 days showed 55.76 ± 47.47 for group 1, 40.27 ± 37.91 for group 2 and 37.12 ± 30.69 for group 3 (p < 0.05 for all groups). Mean increase of serum 25(OH)D3 (nmol/l ± SD) showed 1.32 ± 36.49 for group 1, 6.38 ± 21.19 for group 2 and 18.68 ± 35.45 for group 3 (p > 0.05 for all groups). The results show that the Sun4Health® app is safe to use and can modify behaviour to reduce skin erythema (sunburn) yet not decreasing vitamin D status.

Expansion microscopy with ninefold swelling (NIFS) hydrogel permits cellular ultrastructure imaging on conventional microscope.

Superresolution microscopy enables probing of cellular ultrastructures. However, its widespread applications are limited by the need for expensive machinery, specific hardware, and sophisticated data processing. Expansion microscopy (ExM) improves the resolution of conventional microscopy by physically expanding biological specimens before imaging and currently provides ~70-nm resolution, which still lags behind that of modern superresolution microscopy (~30 nm). Here, we demonstrate a ninefold swelling (NIFS) hydrogel, that can reduce ExM resolution to 31 nm when using regular traditional microscopy. We also design a detachable chip that integrates all the experimental operations to facilitate the maximal reproducibility of this high-resolution imaging technology. We demonstrate this technique on the superimaging of nuclear pore complex and clathrin-coated pits, whose structures can hardly be resolved by conventional microscopy. The method presented here offers a universal platform with superresolution imaging to unveil cellular ultrastructural details using standard conventional laboratory microscopes.

Sickle-like Inertial Microfluidic System for Online Rare Cell Separation and Tandem Label-Free Quantitative Proteomics (Orcs-Proteomics).

Label-free proteomics with trace clinical samples provides a wealth of actionable insights for personalized medicine. Clinically acquired primary cells, such as circulating tumor cells (CTCs), are usually with low abundance that is prohibitive for conventional label-free proteomics analysis. Here, we present a sickle-like inertial microfluidic system for online rare cell separation and tandem label-free proteomics (namely, Orcs-proteomics). Orcs-proteomics adopts a buffer system with 0.1% N-dodecyl ß-d-maltoside (DDM), 1 mM Tris (2-carboxyethyl) phosphine (TCEP), and 2 mM 2-chloroacetamide (CAA) for cell lysis and reductive alkylation. We demonstrate the application of Orcs-proteomics with 293T cells and manage to identify 913, 1563, 2271, and 2770 protein groups with 4, 13, 68, and 119 cells, respectively. We then spike MCF7 cells with white blood cells (WBCs) to simulate the patient's blood sample. Orcs-proteomics identifies more than 2000 protein groups with an average of 61 MCF7 cells. We further recruit two advanced breast cancer patients and collect 5 and 7 CTCs from each patient through minimally invasive blood drawing. Orcs-proteomics manages to identify 973 and 1135 protein groups for each patient. Therefore, Orcs-proteomics empowers rare cells simultaneously to be separated and counted for proteomics and provides technical support for personalized treatment decision making with rare primary patient samples.