Online Ratings of Primary Care Physicians: Comparison of Gender, Training, and Specialty.

The purpose of this study was to explore patient perceptions of primary care providers and their offices relative to their physician's philosophy (medical degree [MD] vs doctorate in osteopathic medicine [DO]), specialty (internal medicine vs family medicine), US region, and gender (male vs female). Using the Healthgrades website, the average satisfaction rating for the physician, office parameters, and wait time were collected and analyzed for 1267 physicians. We found female doctors tended to have lower ratings in the Midwest, and staff friendliness of female physicians were rated lower in the northwest. In the northeast, male and female MDs were rated more highly than DOs. Wait times varied regionally, with northeast and northwest regions having the shortest wait times. Overall satisfaction was generally high for most physicians. Regional differences in perception of a physician based on gender or degree may have roots in local culture, including proximity to a DO school, comfort with female physicians, and expectations for waiting times.

Quantitative assessment of distant recurrence risk in early stage breast cancer using a nonlinear combination of pathological, clinical and imaging variables.

Use of genomic assays to determine distant recurrence risk in patients with early stage breast cancer has expanded and is now included in the American Joint Committee on Cancer staging manual. Algorithmic alternatives using standard clinical and pathology information may provide equivalent benefit in settings where genomic tests, such as OncotypeDx, are unavailable. We developed an artificial neural network (ANN) model to nonlinearly estimate risk of distant cancer recurrence. In addition to clinical and pathological variables, we enhanced our model using intraoperatively determined global mammographic breast density (MBD) and local breast density (LBD). LBD was measured with optical spectral imaging capable of sensing regional concentrations of tissue constituents. A cohort of 56 ER+ patients with an OncotypeDx score was evaluated. We demonstrated that combining MBD/LBD measurements with clinical and pathological variables improves distant recurrence risk prediction accuracy, with high correlation (r = 0.98) to the OncotypeDx recurrence score.

Stereoselective synthesis of the C14-C23 fragment of biselyngbyolide A and B enabled by transition metal catalysis.

Transition met al catalysis has enabled the highly stereoselective and protecting group-free synthesis of the C14-C23 fragment of the apoptosis-inducing natural products biselyngbyolide A and B. A Pd-catalyzed Stille reaction between a vinyl stannane and a crotyl carbonate formed the skipped diene with complete control of the the trisubstituted bond and excellent control over the branched/linear products. A Cu-catalyzed Stahl oxidation was used to form the requisite aldehyde needed for a Ag-catalyzed asymmetric allylation. The latter provided the final fragment with excellent stereochemical control.

Assessment of the Drug Interaction Potential of Unconjugated and GalNAc3-Conjugated 2'-MOE-ASOs.

Antisense oligonucleotides are metabolized by nucleases and drug interactions with small drug molecules at either the cytochrome P450 (CYP) enzyme or transporter levels have not been observed to date. Herein, a comprehensive in vitro assessment of the drug-drug interaction (DDI) potential was carried out with four 2'-O-(2-methoxyethyl)-modified antisense oligonucleotides (2'-MOE-ASOs), including a single triantennary N-acetyl galactosamine (GalNAc3)-conjugated ASO. Several investigations to describe the DDI potential of a 2'-MOE-ASO conjugated to a high-affinity ligand for hepatocyte-specific asialoglycoprotein receptors are explored. The inhibition on CYP1A2, CYP2B6, CYP2C8, CYP2C9, CYP2C19, CYP2D6, CYP2E1, and CYP3A4 and induction on CYP1A2, CYP2B6, and CYP3A4 were investigated in cryopreserved hepatocytes using up to 100 µM of each ASO. No significant inhibition (half maximal inhibitory concentration [IC50] > 100 µM) or induction was observed based on either enzymatic phenotype or mRNA levels. In addition, transporter interaction studies were conducted with nine major transporters per recommendations from regulatory guidances and included three hepatic uptake transporters, organic cation transporter 1 (OCT1), organic anion transporting polypeptide 1B1 (OATP1B1), and OATP1B3; three renal uptake transporters, organic anion transporter 1 (OAT1), OAT3, and OCT2; and three efflux transporters, P-glycoprotein (P-gp), breast cancer resistance protein (BCRP), and bile salt export pump (BSEP). None of the four ASOs (10 µM) were substrates of any of the nine transporters, with uptake <2-fold compared to controls, and efflux ratios were below 2.0 for BCRP and P-gp. Additionally, neither of the four ASOs showed meaningful inhibition on any of the nine transporters tested, with the mean percent inhibition ranging from -38.3% to 24.2% with 100 µM ASO. Based on these findings, the unconjugated and GalNAc3-conjugated 2'-MOE-ASOs would have no or minimal DDI with small drug molecules via any major CYP enzyme or drug transporters at clinically relevant exposures.

Miniature spectral imaging device for wide-field quantitative functional imaging of the morphological landscape of breast tumor margins.

We have developed a portable, breast margin assessment probe leveraging diffuse optical spectroscopy to quantify the morphological landscape of breast tumor margins during breast conserving surgery. The approach presented here leverages a custom-made 16-channel annular photodiode imaging array (arranged in a 4 × 4 grid), a raster-scanning imaging platform with precision pressure control, and compressive sensing with an optimized set of eight wavelengths in the visible spectral range. A scalable Monte-Carlo-based inverse model is used to generate optical property [ ? s ? ( ? ) and ? a ( ? ) ] measures for each of the 16 simultaneously captured diffuse reflectance spectra. Subpixel sampling (0.75 mm) is achieved through incremental x , y raster scanning of the imaging probe, providing detailed optical parameter maps of breast margins over a 2 × 2 ?? cm 2 area in ? 9 ?? min . The morphological landscape of a tumor margin is characterized using optical surrogates for the fat to fibroglandular content ratio, which has demonstrated diagnostic utility in delineating tissue subtypes in the breast.

Development of a simple, rapid, and robust intrathecal catheterization method in the rat.

BACKGROUND: The blood brain barrier (BBB) is an impediment to the development of large and highly charged molecules as therapeutics for diseases and injuries of the central nervous system (CNS). Antisense oligonucleotides (ASOs) are large (6000-8000MW) and highly charged and therefore do not cross the BBB. A method of circumventing the blood brain barrier to test ASOs, and other non-BBB penetrant molecules, as CNS therapeutics is the direct administration of these molecules to the CNS tissue or cerebral spinal fluid. NEW METHOD: We developed a rapid, simple and robust method for the intrathecal catheterization of rats to test putatively therapeutic antisense oligonucleotides. This method utilizes 23-gauge needles, simply constructed ½in. long 19-gauge guide cannulas and 8cm long plastic PE-10 sized catheters. COMPARISON WITH EXISTING METHODS: Unlike the cisterna magna approach, this method uses a lumbar approach for intrathecal catheterization with the catheter residing entirely in the cauda equina space minimizing spinal cord compression. Readily available materials and only a few specialized pieces of equipment, which are easily manufactured, are used for this intrathecal catheterization method. CONCLUSIONS: This method is easy to learn and has been taught to multiple in house surgeons, collaborators and contract laboratories. Greater than 90% catheterization success is routinely achieved with this method and as many as 100 catheters can be placed and test substance administered in one 6-h period. This method has allowed the pre-clinical testing of hundreds of ASOs as therapeutics for CNS indications.

Tau reduction prevents neuronal loss and reverses pathological tau deposition and seeding in mice with tauopathy.

Accumulation of hyperphosphorylated tau directly correlates with cognitive decline in Alzheimer's disease and other primary tauopathies. One therapeutic strategy may be to reduce total tau expression. We identified antisense oligonucleotides (ASOs) that selectively decreased human tau mRNA and protein in mice expressing mutant P301S human tau. After reduction of human tau in this mouse model of tauopathy, fewer tau inclusions developed, and preexisting phosphorylated tau and Thioflavin S pathology were reversed. The resolution of tau pathology was accompanied by the prevention of hippocampal volume loss, neuronal death, and nesting deficits. In addition, mouse survival was extended, and pathological tau seeding was reversed. In nonhuman primates, tau ASOs distributed throughout the brain and spinal cord and reduced tau mRNA and protein in the brain, spinal cord, and cerebrospinal fluid. These data support investigation of a tau-lowering therapy in human patients who have tau-positive inclusions even after pathological tau deposition has begun.

Lack of Interactions Between an Antisense Oligonucleotide with 2'-O-(2-Methoxyethyl) Modifications and Major Drug Transporters.

ISIS 141923 is a model compound of 2'-O-(2-methoxyethyl) (2'-MOE) modified antisense oligonucleotides (ASOs). The purpose of this study is to determine whether ISIS 141923 is a substrate or an inhibitor against a panel of nine major uptake or efflux drug transporters, namely breast cancer resistance protein (BCRP), P-glycoprotein (P-gp), organic anion transporter (OAT)1, OAT3, organic cation transporter (OCT)1, OCT2, organic anion transporting polypeptide 1B (OATP1B)1, OATP1B3, and bile salt export pump (BSEP), in vitro. The uptake test system for transporters in the solute carrier (SLC) family (OAT1, OAT3, OCT1, OCT2, OATP1B1, and OATP1B3) was studied in Madin-Darby canine kidney (MDCK)-II cells transfected to express the transporters of interest. BCRP was studied using carcinoma colon-2 (Caco-2) cells with endogenously expressed BCRP. P-gp transporter was studied in MDCK-multi-drug resistance 1 (MDR1) cells, while BSEP was studied using Spodoptera frugiperda 9 (Sf9) membrane vesicles containing human BSEP. The ISIS 141293 concentrations evaluated were 10 and 100 µM for the substrate and inhibition study, respectively. Cellular uptake of ISIS 141923 was analyzed using a high performance liquid chromatography-mass spectrometry method, while concentrations of known substrates (used as positive controls) of each transporters evaluated were determined by radiometric detection. At 10 µM ISIS 141923, there was no significant transporter-mediated uptake of ISIS 141923 (P > 0.05) in the SLC family, and the efflux ratios were not above 2.0 for either BCRP or P-gp. Therefore, no transporter-mediated uptake of ISIS 141923 was observed by any of the nine transporters studied. At 100 µM ISIS 141923, the % inhibition was in the range of -16.0% to 19.0% for the nine transporters evaluated. Therefore, ISIS 141923 is not considered as an inhibitor of the nine transporters studied. Overall, the results from this study suggest that it is unlikely that ISIS 141923 or similar 2'-MOE ASOs would interact with small molecule drugs either as a victim (substrate) or perpetrator (inhibitor) of major transporters in humans. The results from available clinical drug-drug interaction studies conducted with this class of compounds to date are also supportive of this conclusion.

A Quantitative Diffuse Reflectance Imaging (QDRI) System for Comprehensive Surveillance of the Morphological Landscape in Breast Tumor Margins.

In an ongoing effort to address the clear clinical unmet needs surrounding breast conserving surgery (BCS), our group has developed a next-generation multiplexed optical-fiber-based tool to assess breast tumor margin status during initial surgeries. Specifically detailed in this work is the performance and clinical validation of a research-grade intra-operative tool for margin assessment based on diffuse optical spectroscopy. Previous work published by our group has illustrated the proof-of-concept generations of this device; here we incorporate a highly optimized quantitative diffuse reflectance imaging (QDRI) system utilizing a wide-field (imaging area = 17 cm(2)) 49-channel multiplexed fiber optic probe, a custom raster-scanning imaging platform, a custom dual-channel white LED source, and an astronomy grade imaging CCD and spectrograph. The system signal to noise ratio (SNR) was found to be greater than 40 dB for all channels. Optical property estimation error was found to be less than 10%, on average, over a wide range of absorption (µa = 0-8.9 cm(-1)) and scattering (µs' = 7.0-9.7 cm(-1)) coefficients. Very low inter-channel and CCD crosstalk was observed (2% max) when used on turbid media (including breast tissue). A raster-scanning mechanism was developed to achieve sub-pixel resolution and was found to be optimally performed at an upsample factor of 8, affording 0.75 mm spatially resolved diffuse reflectance images (λ = 450-600 nm) of an entire margin (area = 17 cm(2)) in 13.8 minutes (1.23 cm(2)/min). Moreover, controlled pressure application at the probe-tissue interface afforded by the imaging platform reduces repeated scan variability, providing <1% variation across repeated scans of clinical specimens. We demonstrate the clinical utility of this device through a pilot 20-patient study of high-resolution optical parameter maps of the ratio of the ß-carotene concentration to the reduced scattering coefficient. An empirical cumulative distribution function (eCDF) analysis is used to reduce optical property maps to quantitative distributions representing the morphological landscape of breast tumor margins. The optimizations presented in this work provide an avenue to rapidly survey large tissue areas on intra-operative time scales with improved sensitivity to regions of focal disease that may otherwise be overlooked.

Clinical study of noninvasive in vivo melanoma and nonmelanoma skin cancers using multimodal spectral diagnosis.

The goal of this study was to determine the diagnostic capability of a multimodal spectral diagnosis (SD) for in vivo noninvasive disease diagnosis of melanoma and nonmelanoma skin cancers. We acquired reflectance, fluorescence, and Raman spectra from 137 lesions in 76 patients using custom-built optical fiber-based clinical systems. Biopsies of lesions were classified using standard histopathology as malignant melanoma (MM), nonmelanoma pigmented lesion (PL), basal cell carcinoma (BCC), actinic keratosis (AK), and squamous cell carcinoma (SCC). Spectral data were analyzed using principal component analysis. Using multiple diagnostically relevant principal components, we built leave-one-out logistic regression classifiers. Classification results were compared with histopathology of the lesion. Sensitivity/specificity for classifying MM versus PL (12 versus 17 lesions) was 100%/100%, for SCC and BCC versus AK (57 versus 14 lesions) was 95%/71%, and for AK and SCC and BCC versus normal skin (71 versus 71 lesions) was 90%/85%. The best classification for nonmelanoma skin cancers required multiple modalities; however, the best melanoma classification occurred with Raman spectroscopy alone. The high diagnostic accuracy for classifying both melanoma and nonmelanoma skin cancer lesions demonstrates the potential for SD as a clinical diagnostic device.

68Ga chelating bioorthogonal tetrazine polymers for the multistep labeling of cancer biomarkers.

We have developed a (68)Ga metal chelating bioorthogonal tetrazine dextran probe that is highly reactive with trans-cyclooctene modified monoclonal antibodies for multistep imaging applications. Confocal microscopy and positron emission tomography (PET) were used to characterize the dextran probe in vitro and in vivo.

Use of craniofacial superimposition in historic investigation.

A skeleton discovered in Grand Forks, North Dakota was purported to belong to Clelland "Clell" Miller, a James-Younger gang member, who was killed during the Northfield Bank robbery on September 7, 1876. A 3-D image from a computer tomography (CT) scan of the skull was obtained, and a craniofacial superimposition was conducted to determine if the skull could belong to Miller. The superimposition method used in this case was to overlay the CT image of the skull onto Miller's postmortem photograph. In addition to the craniofacial superimposition, the images were juxtaposed to compare similarities or differences in facial morphology between the skull and photograph. Superimposition methods can be used to exclude identifications; however, they should not be used as a conclusive method for identification. In this case, there were sufficient similarities between the skull and Miller's photograph; therefore, the skull could not be eliminated as possibly being that of Miller.

A diffuse reflectance spectral imaging system for tumor margin assessment using custom annular photodiode arrays.

Diffuse reflectance spectroscopy (DRS) is a well-established method to quantitatively distinguish between benign and cancerous tissue for tumor margin assessment. Current multipixel DRS margin assessment tools are bulky fiber-based probes that have limited scalability. Reported herein is a new approach to multipixel DRS probe design, which utilizes direct detection of the DRS signal by using optimized custom photodetectors in direct contact with the tissue. This first fiberless DRS imaging system for tumor margin assessment consists of a 4 × 4 array of annular silicon photodetectors and a constrained free-space light delivery tube optimized to deliver light across a 256 mm(2) imaging area. This system has 4.5 mm spatial resolution. The signal-to-noise ratio measured for normal and malignant breast tissue-mimicking phantoms was 35 dB to 45 dB for λ = 470 nm to 600 nm.

Performance of a lookup table-based approach for measuring tissue optical properties with diffuse optical spectroscopy.

Diffuse optical spectroscopy (DOS) provides a powerful tool for fast and noninvasive disease diagnosis. The ability to leverage DOS to accurately quantify tissue optical parameters hinges on the model used to estimate light-tissue interaction. We describe the accuracy of a lookup table (LUT)-based inverse model for measuring optical properties under different conditions relevant to biological tissue. The LUT is a matrix of reflectance values acquired experimentally from calibration standards of varying scattering and absorption properties. Because it is based on experimental values, the LUT inherently accounts for system response and probe geometry. We tested our approach in tissue phantoms containing multiple absorbers, different sizes of scatterers, and varying oxygen saturation of hemoglobin. The LUT-based model was able to extract scattering and absorption properties under most conditions with errors of less than 5 percent. We demonstrate the validity of the lookup table over a range of source-detector separations from 0.25 to 1.48 mm. Finally, we describe the rapid fabrication of a lookup table using only six calibration standards. This optimized LUT was able to extract scattering and absorption properties with average RMS errors of 2.5 and 4 percent, respectively.

Effects of mechanical indentation on diffuse reflectance spectra, light transmission, and intrinsic optical properties in ex vivo porcine skin.

BACKGROUND AND OBJECTIVES: Mechanical indentation has been shown to increase light transmission through turbid tissue. In this study, we investigated the effects of localized indentation on the optical properties of ex vivo porcine skin specimens by dynamically monitoring diffuse reflectance spectra, light transmission, and applied load while controlling tissue thickness. STUDY DESIGN/METHODS: A custom-built diffuse reflectance spectroscopy (DRS) system was used to capture diffuse reflectance spectra from tissue specimens undergoing indentation. The DRS probe was designed to perform both optical sensing and tissue indentation. A mechanical load frame was used to dynamically control probe displacement and resultant specimen thickness change while recording applied load. Diffuse reflectance spectra, as well as light transmission at 630 nm, were recorded during stress relaxation tests where tissue specimens were displaced to and held at a final thickness. Tissue optical properties were extracted from reflectance spectra using a previously established look-up table (LUT) approach. RESULTS: Indentation increased light transmission through tissue during linear displacement, and continued to increase transmission during subsequent stress relaxation at constant tissue thickness. The magnitude of relative transmission increases was shown to be a function of bulk tissue compressive strain (relative thickness change). Reduced scattering coefficients calculated from the LUT at 630 nm decreased during stress relaxation, with the relative decrease in scattering also depending strongly on tissue compressive strain. Reduced scattering coefficients decreased by 12.0 ± 4.7% at 0.44 ± 0.022 compressive strain, and reduced by 35.6 ± 1.3% at 0.71 ± 0.01 compressive strain. CONCLUSION: DRS can be used to capture transient changes in intrinsic tissue optical properties during mechanical loading. Mechanical indentation modifies tissue optical properties and may be harnessed as a minimally-invasive optical clearing technique to improve optical diagnostics and therapeutics.

Development of a noncontact diffuse optical spectroscopy probe for measuring tissue optical properties.

Optical reflectance probes are often used as tools to obtain optical spectra from superficial tissues and subsequently determine optical and physiological properties associated with early stage cancer. These probes, when placed directly on the tissue, are known to cause significant pressure-dependent changes in local optical properties. To address this, we fit the probe with an optical device that images the illumination and collection fibers onto the tissue surface, eliminating the influence of contact probe pressure on the sampling area. The noncontact probe addition addresses new optical conditions that may affect its performance such as tissue surface contour, and specular reflections by implementing an autofocusing mechanism and cross polarization. Extracted optical properties of tissue simulating phantoms yield errors of 3.46% in reduced scattering and 8.62% in absorbance. Autofocusing has extended the depth of field from 4 mm to throughout the 12 mm range of autofocus travel, while cross polarization has removed the incidence angle dependent specular reflection component from the collected signal.

Changes in morphology and optical properties of sclera and choroidal layers due to hyperosmotic agent.

Light scattering in the normally white sclera prevents diagnostic imaging or delivery of a focused laser beam to a target in the underlying choroid layer. In this study, we examine optical clearing of the sclera and changes in blood flow resulting from the application of glycerol to the sclera of rabbits. Recovery dynamics are monitored after the application of saline. The speed of clearing for injection delivery is compared to the direct application of glycerol through an incision in the conjunctiva. Although, the same volume of glycerol was applied, the sclera cleared much faster (5 to 10 s) with the topical application of glycerol compared to the injection method (3 min). In addition, the direct topical application of glycerol spreads over a larger area in the sclera than the latter method. A diffuse optical spectroscopy system provided spectral analysis of the remitted light every two minutes during clearing and rehydration. Comparison of measurements to those obtained from phantoms with various absorption and scattering properties provided estimates of the absorption coefficient and reduced scattering coefficient of rabbit eye tissue.

Probe pressure effects on human skin diffuse reflectance and fluorescence spectroscopy measurements.

Diffuse reflectance and fluorescence spectroscopy are popular research techniques for noninvasive disease diagnostics. Most systems include an optical fiber probe that transmits and collects optical spectra in contact with the suspected lesion. The purpose of this study is to investigate probe pressure effects on human skin spectroscopic measurements. We conduct an in-vivo experiment on human skin tissue to study the short-term (<2 s) and long-term (>30 s) effects of probe pressure on diffuse reflectance and fluorescence measurements. Short-term light probe pressure (P0<9 mN∕mm2) effects are within 0 ± 10% on all physiological properties extracted from diffuse reflectance and fluorescence measurements, and less than 0±5% for diagnostically significant physiological properties. Absorption decreases with site-specific variations due to blood being compressed out of the sampled volume. Reduced scattering coefficient variation is site specific. Intrinsic fluorescence shows a large standard error, although no specific pressure-related trend is observed. Differences in tissue structure and morphology contribute to site-specific probe pressure effects. Therefore, the effects of pressure can be minimized when the pressure is small and applied for a short amount of time; however, long-term and large pressures induce significant distortions in measured spectra.

A wandering liver.

A wandering liver has been described throughout modern medical literature as a rare entity. During the last few years, an increasing number of cases have been reported associated with colonic volvulus. We report a 17-year-old with a hypermobile liver seen on multiple radiographs and CT. The intraoperative findings demonstrated the liver in its normal anatomic position. We suggest that this entity is more common than thought, and the rise in incidence is likely secondary to increased utilization of pre-operative imaging of patients with colonic obstruction. Increased suspicion might result in further increased incidence of this exceedingly rare entity.