Electronic Health Record-Based Nudge Intervention and Axillary Surgery in Older Women With Breast Cancer: A Nonrandomized Controlled Trial.

Importance: Choosing Wisely recommendations advocate against routine use of axillary staging in older women with early-stage, clinically node-negative (cN0), hormone receptor-positive (HR+), and HER2-negative breast cancer. However, rates of sentinel lymph node biopsy (SLNB) in this population remain persistently high. Objective: To evaluate whether an electronic health record (EHR)-based nudge intervention targeting surgeons in their first outpatient visit with patients meeting Choosing Wisely criteria decreases rates of SLNB. Design, Setting, and Participants: This nonrandomized controlled trial was a hybrid type 1 effectiveness-implementation study with subsequent postintervention semistructured interviews and lasted from October 2021 to October 2023. Data came from EHRs at 8 outpatient clinics within an integrated health care system; participants included 7 breast surgical oncologists. Data were collected for female patients meeting Choosing Wisely criteria for omission of SLNB (aged ≥70 years with cT1 and cT2, cN0, HR+/HER2- breast cancer). The study included a 12-month preintervention control period; baseline surveys assessing perceived acceptability, appropriateness, and feasibility of the designed intervention; and a 12-month intervention period. Intervention: A column nudge was embedded into the surgeon's schedule in the EHR identifying patients meeting Choosing Wisely criteria for potential SLNB omission. Main Outcomes and Measures: The primary outcome was rate of SLNB following nudge deployment into the EHR. Results: Similar baseline demographic and tumor characteristics were observed before (control period, n = 194) and after (intervention period, n = 193) nudge deployment. Patients in both the control and intervention period had a median (IQR) age of 75 (72-79) years. Compared with the control period, unadjusted rates of SLNB decreased by 23.1 percentage points (46.9% SLNB rate prenudge to 23.8% after; 95% CI, -32.9 to -13.8) in the intervention period. An interrupted time series model showed a reduction in the rate of SLNB following nudge deployment (adjusted odds ratio, 0.26; 95% CI, 0.07 to 0.90; P = .03). The participating surgeons scored the intervention highly on acceptability, appropriateness, and feasibility. Dominant themes from semistructured interviews indicated that the intervention helped remind the surgeons of potential Choosing Wisely applicability without the need for additional clicks or actions on the day of the patient visit, which facilitated use. Conclusions and Relevance: This study showed that a nudge intervention in the EHR significantly decreased low-value axillary surgery in older women with early-stage, cN0, HR+/HER2- breast cancer. This user-friendly and easily implementable EHR-based intervention could be a beneficial approach for decreasing low-value care in other practice settings or patient populations. Trial Registration: ClinicalTrials.gov Identifier: NCT06006910.

Understanding the Complexity of Microbiology Method Validation to Meet State Specific Requirements for Cannabis.

BACKGROUND: Federal legislation still prohibits the cultivation, sale and consumption of cultivars of delta 9-tetrahydrocannabinol cannabis (>0.3%), however, as of November 2022, 39 states have legalized these products for medicinal consumption and 21 states have legalized for adult-use consumption. This state-by-state approach has produced a patch work of regulations that multi-state operators (MSO) must learn to navigate. Furthermore cannabis laboratories often lack the space and skill needed to perform method validations adding another layer of complexity. While these barriers exist, it is paramount for MSOs to demonstrate the fitness of purpose of their methods. OBJECTIVE: This review presents the complexity that a MSOs navigated in developing microbiology method validation study designs for two proprietary Real-Time PCR (RT-PCR) assays to meet four state (California, Florida, Michigan and Oklahoma) testing requirements. The testing in each state was conducted in addition to certification of the assays through the AOAC Performance Tested Method  SM (PTM) program. METHODS: Matrix studies were conducted targeting three analytes (Aspergillus spp., Salmonella spp., and Shiga toxin-producing Escherichia coli) as directed by the state regulatory authorities. For California, inclusivity and exclusivity studies were performed. The number of contamination levels, test portion replicates, and total target organisms evaluated varied by state. Culture confirmation was not performed outside of the AOAC PTM studies. RESULTS: Data from each study was collected, summarized, and provided to the state regulatory agencies. Review of the data consisted of identifying discrepant results and verification of controls. After review, each assay was certified for use in the respective state. CONCLUSION: Requirements from each of the states demonstrate the complexities MSO face and emphasize the need for a more standardized approach to streamline acceptance of alternative methods. HIGHLIGHTS: While varying state regulations can be complex, validation studies performed for the candidate methods have led to adoption across 31 states.

Response in axillary lymph nodes to neoadjuvant chemotherapy for breast cancers: correlation with breast response, pathologic features, and accuracy of radioactive seed localization.

OBJECTIVES: This study examined the accuracy of radioactive seed localization (RSL) of lymph nodes (LNs) following neoadjuvant chemotherapy (NAC) for invasive breast carcinoma, recorded pathologic features of LNs following NAC, evaluated concordance of response between breast and LNs, and identified clinicopathologic factors associated with higher risk of residual lymph node involvement. METHODS: Clinical records, imaging, and pathology reports and slides were retrospectively reviewed for 174 breast cancer patients who received NAC. Chi-square and Fisher's exact tests were used to compare differences in risk of residual lymph node disease. RESULTS: Retrieval of biopsied pre-therapy positive LN was confirmed in 86/93 (88%) cases overall, and in 75/77 (97%) of cases utilizing RSL. Biopsy clip site was the best pathologic feature to confirm retrieval of a biopsied lymph node. Pre-therapy clinical N stage > 0, positive pre-therapy lymph node biopsy, estrogen and progesterone receptor positivity, Ki67 < 50%, HR + /HER2- tumors, and residual breast disease had higher likelihood of residual lymph node disease after NAC (p < 0.001). CONCLUSIONS: RSL-guided LN excision improves retrieval of previously biopsied LNs following NAC. The pathologist can use histologic features to confirm retrieval of targeted LNs, and tumor characteristics can be used to predict a higher risk of residual LN involvement.

Single-institution outcomes after excision of benign phyllodes tumors: low recurrence risk even with positive margins.

PURPOSE: Benign phyllodes tumors (BPT) are rare breast neoplasms with clinical behavior that poses low recurrence risk. Guidelines regarding appropriate margins recommend surgical excision to negative margins, sometimes requiring re-excision surgery. Contemporary experience suggests that re-excision in the face of positive margins may not be needed. METHODS: This is a retrospective review of a single-institution experience with BPT from 2010 to 2019 with 102 patients. Demographics, outcomes and follow-up were analyzed. RESULTS: The median age was 37 years. 95% had a pre-operative biopsy and only 6% were confirmed BPT before surgery.56% had positive margins and were more likely to be younger and have a pre-operative diagnosis of fibroadenoma. The median follow-up was 33 months. Between the positive and negative margin groups, recurrence rates were not significantly different (p = 0.87). CONCLUSION: Positive margins on excision of BPT poses a low recurrence risk and re-excision surgery is not necessary.

Dosimetry and Toxicity Outcomes in Patients Treated with Hypofractionated Regional Nodal Irradiation for Breast Cancer: What is the Best Dose-Volume Limit to Minimize Risks of Radiation Pneumonitis?

PURPOSE: Although published data have supported the use of hypofractionated regional nodal irradiation (HF-RNI) for breast cancer, limited dosimetric data exist to evaluate predictors of lung toxicity. The ongoing RT CHARM trial limits the percentage of ipsilateral lung volume that receives ≥18 Gy to 35 to 40%. We assessed dosimetry, toxicity, and disease outcomes in patients with breast cancer treated with HF-RNI with a particular focus on pneumonitis. METHODS AND MATERIALS: We retrospectively reviewed all patients with breast cancer treated with HF-RNI (40-43 Gy in 15-16 fractions) after either lumpectomy or mastectomy at The University of Pittsburgh Medical Center from September 2018 to December 2021 to collect dosimetric and outcomes data. All post-radiation therapy chest computed tomography (CT) scans were manually reviewed for evidence of acute (≤6 months postradiation) or chronic (>6 months postradiation) pneumonitis. RESULTS: One-hundred-ninety-one patients qualified with a median follow-up of 20.3 months (range, 5.1-42.2). Acute grade 1 (G1) pneumonitis was observed in 6.8% of the overall cohort (13 of 191 patients) and 39.4% of the patients (13 of 33) who received a chest CT ≤6 months postradiation therapy. Only 1 patient developed acute G2 pneumonitis. Chronic G1 pneumonitis was observed in 29.8% of the overall cohort (57 of 191 patients) and 77% of patients (57 of 74 patients) who received a chest CT >6 months postradiation therapy. No patients developed acute G3+ or chronic G2+ pneumonitis. CONCLUSIONS: Rates of symptomatic pneumonitis were low in this cohort of patients treated with HF-RNI, even with integration of HER2/neu-directed therapy, chemotherapy, hormone therapy, and internal mammary nodal irradiation. Lung V20Gy <26% appeared safe in this cohort to limit symptomatic pneumonitis, though this is not meant to represent the safe upper limit. Given the low event rate of symptomatic pneumonitis, data from larger cohorts will be needed to assess dosimetric predictors and the safe upper limit of lung dose.

Association between Self-reported Sleep Quality and Single-task Gait in Young Adults: A Study Using Machine Learning.

Objective The objective of the present study was to find biomechanical correlates of single-task gait and self-reported sleep quality in a healthy, young population by replicating a recently published study. Materials and Methods Young adults ( n = 123) were recruited and were asked to complete the Pittsburgh Sleep Quality Inventory to assess sleep quality. Gait variables ( n = 53) were recorded using a wearable inertial measurement sensor system on an indoor track. The data were split into training and test sets and then different machine learning models were applied. A post-hoc analysis of covariance (ANCOVA) was used to find statistically significant differences in gait variables between good and poor sleepers. Results AdaBoost models reported the highest correlation coefficient (0.77), with Support-Vector classifiers reporting the highest accuracy (62%). The most important features associated with poor sleep quality related to pelvic tilt and gait initiation. This indicates that overall poor sleepers have decreased pelvic tilt angle changes, specifically when initiating gait coming out of turns (first step pelvic tilt angle) and demonstrate difficulty maintaining gait speed. Discussion The results of the present study indicate that when using traditional gait variables, single-task gait has poor accuracy prediction for subjective sleep quality in young adults. Although the associations in the study are not as strong as those previously reported, they do provide insight into how gait varies in individuals who report poor sleep hygiene. Future studies should use larger samples to determine whether single task-gait may help predict objective measures of sleep quality especially in a repeated measures or longitudinal or intervention framework.

An NTP-driven mechanism for the nucleotide addition cycle of Escherichia coli RNA polymerase during transcription.

The elementary steps of transcription as catalyzed by E. coli RNA polymerase during one and two rounds of the nucleotide addition cycle (NAC) were resolved in rapid kinetic studies. Modelling of stopped-flow kinetic data of pyrophosphate release in a coupled enzyme assay during one round of the NAC indicates that the rate of pyrophosphate release is significantly less than that for nucleotide incorporation. Upon modelling of the stopped-flow kinetic data for pyrophosphate release during two rounds of the NAC, it was observed that the presence of the next nucleotide for incorporation increases the rate of release of the first pyrophosphate equivalent; incorrect nucleotides for incorporation had no effect on the rate of pyrophosphate release. Although the next nucleotide for incorporation increases the rate of pyrophosphate release, it is still significantly less than the rate of incorporation of the first nucleotide. The results from the stopped-flow kinetic studies were confirmed by using quench-flow followed by thin-layer chromatography (QF-TLC) with only the first nucleotide for incorporation labeled on the gamma phosphate with 32P to monitor pyrophosphate release. Collectively, the results are consistent with an NTP-driven model for the NAC in which the binding of the next cognate nucleotide for incorporation causes a synergistic conformational change in the enzyme that triggers the more rapid release of pyrophosphate, translocation of the enzyme along the DNA template strand and nucleotide incorporation.

Timely cancer genetic counseling and testing for young women with breast cancer: impact on surgical decision-making for contralateral risk-reducing mastectomy.

PURPOSE: Genetic testing (GT) can identify individuals with pathogenic/likely pathogenic variants (PV/LPVs) in breast cancer (BC) predisposition genes, who may consider contralateral risk-reducing mastectomy (CRRM). We report on CRRM rates in young women newly diagnosed with BC who received GT through a multidisciplinary clinic. METHODS: Clinical data were reviewed for patients seen between November 2014 and June 2019. Patients with non-metastatic, unilateral BC diagnosed at age ≤ 45 and completed GT prior to surgery were included. Associations between surgical intervention and age, BC stage, family history, and GT results were evaluated. RESULTS: Of the 194 patients, 30 (15.5%) had a PV/LPV in a BC predisposition gene (ATM, BRCA1, BRCA2, CHEK2, NBN, NF1), with 66.7% in BRCA1 or BRCA2. Of 164 (84.5%) uninformative results, 132 (68%) were negative and 32 (16.5%) were variants of uncertain significance (VUS). Overall, 67 (34.5%) had CRRM, including 25/30 (83.3%) PV/LPV carriers and 42/164 (25.6%) non-carriers. A positive test result (p < 0.01) and significant family history were associated with CRRM (p = 0.02). For the 164 with uninformative results, multivariate analysis showed that CRRM was not associated with age (p = 0.23), a VUS, (p = 0.08), family history (p = 0.10), or BC stage (p = 0.11). CONCLUSION: In this cohort of young women with BC, the identification of a PV/LPV in a BC predisposition gene and a significant family history were associated with the decision to pursue CRRM. Thus, incorporation of genetic services in the initial evaluation of young patients with a new BC could contribute to the surgical decision-making process.

The National Cancer Institute and Cannabis and Cannabinoids Research.

The landscape of both recreational and medicinal cannabis use has changed dramatically over the past decade; however, research examining the risks and benefits of cannabis and cannabinoid use has lagged significantly behind the increased media promotion and their use by the general public and cancer patients. The National Cancer Institute (NCI) has supported cannabis-related research projects and funding opportunity announcements. In addition, NCI organized a virtual symposium on December 15-18, 2020, to discuss recent research findings on the use of cannabis and cannabinoids in relationship to cancer risk, prevention, and care. Specifically, the symposium sought to highlight the state of the science regarding cannabis, including the chemical constituents of cannabis (eg, cannabinoids), and cancer research involving cannabis, including cancer epidemiology, use in cancer patients, cancer biology and prevention, and preclinical and clinical cancer symptom and treatment side effect management with cannabis and cannabinoids as therapeutics. The symposium identified promising areas of future study, current barriers to conducting the research, and strategies to overcome those barriers. The series of papers in this special edition provide a summary of the symposium sessions as well as a synopsis of opportunities and challenges related to conducting research in this area.

Cutting Instruments to Cut Costs: A Simple Initiative with Breast Surgical Operating Room Trays that Resulted in Substantial Savings.

BACKGROUND: A substantial expense in surgical care is incurred in the operating room (OR). We evaluated the financial impact of a systematic reduction in instrument tray contents on charges for breast surgery procedures. METHODS: A catalog of OR trays historically used for breast procedures (excisional biopsy, segmental and total mastectomy with or without axillary staging) was reviewed by four dedicated breast surgeons and downsized to a single tray accommodating all surgeon preferences. A matched-case comparison was performed pre- and post-downsizing. Cost analysis for salary and benefits (S&B) and unit supply cost (USC) pre- and post-downsizing were carried out. Instrument number, OR tray weights, set-up, and breakdown times were also compared. RESULTS: Post-downsizing, OR tray counts were reduced from 132 to 67 instruments (49%) and tray weight decreased from 30 to 20 pounds (33%). Scrub technician set-up and breakdown times were shorter by 22% and 25%, respectively. Comparing 449 matched cases (239 pre- and 210 post-downsizing), S&B and USC post-downsizing were decreased collectively for all procedures (p < 0.0001). With an average variance of S&B and USC (pre- to post-intervention) of $354, and an annualized case load of 813 operations, this could translate into S&B and USC savings of $287,802 per year. CONCLUSION: Simply downsizing OR breast trays resulted in decreased combined S&B and USC per procedure, leading to a substantial cost savings for the healthcare system. This measure aligns with a value and quality-based approach to patient care and could be easily replicated across institutions and specialties.

Association of Tumor Molecular Subtype and Stage with Breast and Axillary Pathologic Complete Response After Neoadjuvant Chemotherapy for Breast Cancer.

BACKGROUND: Axillary pathologic complete response (pCR) confers higher overall and recurrence-free survival than residual axillary disease. Although breast pCR (ypT0) is associated with a pathologically negative axilla (ypN0) in human epidermal growth factor receptor 2-positive (HER2+) and triple-negative breast cancer (TNBC), how clinical T (cT) and N (cN) staging are associated with ypN0 in other tumor subtypes is incompletely understood. METHODS: A single-institution cancer registry was retrospectively reviewed for patients receiving neoadjuvant chemotherapy (NAC) followed by surgery from 2010 to 2018. Fisher's exact tests compared proportion of breast and axillary pCR by tumor subtype (hormone receptor [HR]-positive /HER2-,HR+/HER2+,HR-/HER2+,HR-/HER2-). Logistic regression determined factors associated with ypN0. Sensitivity analyses determined how cN status affected ypN status by tumor subtype. RESULTS: The study enrolled 1348 patients. The median age was 54 years (interquartile range [IQR], 44-63 years), and 55% of the patients (n = 736) were postmenopausal. The tumor subtypes were HR+/HER2- (12%, n = 155), HR+/HER2+ (48%, n = 653), HR-/HER2+ (25%, n = 343), and TNBC (15%, n = 197). In the study, cT included T0 (1%, n = 18), T1 (20%, n = 272), T2 (53%, n = 713), T3 (17%, n = 230), and T4 (9%, n = 111), and cN included cN0 (51%, n = 687), cN1 (41%, n = 549), cN2 (5%, n = 61), and cN3 (3%, n = 43). Breast pCR and ypN0 occurred most in the HER2+ and TNBC subtypes. A negative association was found between ypN0 and age at diagnosis (odds ratio [OR], 0.98; 95% confidence interval [CI], 0.97-0.99; p < 0.001), cT4 stage (OR, 0.29; 95% CI, 0.09-0.91; p = 0.034), and HR+ subtypes (HR+/HER2-: OR, 0.54; 95% CI, 0.31-0.94; p = 0.028; HR+/HER2+: OR, 0.60; 95% CI, 0.39-0.93; p = 0.024). The HR-/HER2+ subtype was associated with ypN0 (OR, 1.70; 95% CI, 1.05-2.73; p = 0.030), and cN2/cN3 was negatively associated with ypN0 in HR+/HER2+ disease (OR, 0.26; 95% CI, 0.11-0.61; p = 0.002), HR-/HER2+ disease (OR, 0.42; 95% CI, 0.22-0.77; p = 0.005), and TNBC (OR, 0.11; 95% CI, 0.03-0.40; p = 0.001). CONCLUSION: Tumor subtype, clinical stage, and age at diagnosis may be important in consideration of de-escalation of axillary staging.

Evaluation of the GENE-UP® EHEC Detection Method for the Detection of Enterohemorrhagic E. coli in Select Foods: Collaborative Study: First Action Method 2020.06.

BACKGROUND: The GENE-UP® EHEC assay (Performance Tested MethodSM 121806) is a real-time PCR molecular detection method that utilizes fluorescence resonance energy transfer proprietary hybridization probes for the rapid detection of enterohemorrhagic Escherichia coli (EHEC) in select foods. OBJECTIVE: The purpose of this validation was to evaluate the method's interlaboratory performance and submit the results to AOAC INTERNATIONAL for adoption as a First Action Official Method of AnalysisSM for the detection of EHEC in select foods. METHOD: The GENE-UP method was evaluated in a multi-laboratory study as part of the MicroVal VALIDATION certification process using unpaired test portions for one food matrix, raw ground beef (85% lean). Collaborators evaluated the candidate method using either an automated or manual lysis procedure. The candidate method was compared to the ISO/TS 13136:2012 method. Data from 17 participants from 15 laboratories throughout the European Union were evaluated. Three levels of contamination were evaluated: a non-inoculated control level (0 CFU/test portion), a low contamination level (∼1 CFU/test portion), and a high contamination level (∼10 CFU/test portion). Data from the study were analyzed according to the probability of detection (POD) statistical model. RESULTS: The difference in laboratory probability of detection (dLPODC) values with 95% confidence interval between the candidate and reference method results were -0.01 (-0.04, 0.02), 0.23 (0.07, 0.39), and 0.06 (0.01, 0.12) for the non-inoculated, low, and high contamination levels, respectively. CONCLUSIONS: For the candidate method, values obtained for repeatability and reproducibility were similar to the reference method and indicated minimal variation between samples or between laboratories. No discrepant results (false positive or false negative) were observed for each contamination. A statistical difference was calculated between the candidate and reference method at the low and high inoculation levels, with the candidate method detecting a higher number of positive samples indicating a higher sensitivity than the reference method. No differences in the recovery of the target analyte were observed between the manual and automated lysis procedures. HIGHLIGHTS: The GENE-UP EHEC Detection Method provides end users a rapid, easy-to-use workflow for the detection of EHEC in food matrixes.

Validation Study for VERIPRO® SARS-CoV-2 Env Assay for the Detection of SARS-CoV-2 from Stainless-Steel Environmental Surface Swabs: Emergency Response Validation-AOAC Performance Tested MethodSM 122001.

BACKGROUND: The VERIPRO® SARS-CoV-2 Env assay uses reverse transcriptase (RT) PCR to detect SARS-CoV-2, the causative agent of COVID-19, from stainless-steel environmental sample swabs. OBJECTIVE: To validate the VERIPRO SARS-CoV-2 Env assay as part of the AOAC Research Institute's Emergency Response Validation Performance Tested Method(s)SM program. METHOD: The VERIPRO SARS-CoV-2 Env assay was evaluated for specificity using in silico analysis of 15 764 SARS-CoV-2 sequences and 65 exclusivity organisms (both near neighbors and background organisms). The candidate method was evaluated in an unpaired study design for one environmental surface (stainless steel) and compared to the U.S. Centers for Disease Control and Prevention 2019-Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel, Instructions for Use (Revision 4, Effective 6/12/2020). RESULTS: Results of the in silico analysis demonstrate the specificity of the method in being able to detect target sequences and discriminate them from near neighbors. In the matrix study, the candidate method demonstrated statistically significant better recovery of the target analyte than the reference method. CONCLUSIONS: The VERIPRO SARS-CoV-2 Env assay is a rapid and accurate method that can be utilized by food producers to detect the causative agent of COVID-19 on food contact surfaces. HIGHLIGHTS: The VERIPRO SARS-CoV-2 Env assay can be performed without the need for an optional RNA purification step to detect SARS-CoV-2 from environmental surfaces.

Evaluation of the GENE-UP®Salmonella Method for the Detection of Salmonella Species in a Broad Range of Foods and Select Environmental Surfaces: Collaborative Study, First Action 2020.02.

BACKGROUND: The GENE-UP®Salmonella assay (Performance Tested MethodSM [PTM] 121802) is a PCR detection method that utilizes fluorescence resonance energy transfer (FRET) hybridization probes for the rapid detection of Salmonella species in foods and on environmental surfaces. OBJECTIVE: The purpose of this validation was to evaluate the method's interlaboratory performance for submission to AOAC INTERNATIONAL for adoption as First Action Official Method of AnalysisSM. METHOD: The GENE-UP method was evaluated in a multi-laboratory study using unpaired test portions for one food matrix, raw ground beef (80% lean). The candidate method was compared to the US Department of Agriculture (USDA), Food Safety Inspection Service, Microbiology Laboratory Guidebook (MLG) 4.10 reference method. An alternative confirmation procedure, using ASAP™ and CHROMID®Salmonella chromogenic agars, was included in the validation study. Fifteen collaborators from 14 laboratories participated. Three levels of contamination were evaluated: a non-inoculated control level (0 CFU/test portion), a low contamination level (∼0.7 CFU/test portion), and a high contamination level (∼2 CFU/test portion). Data were analyzed using the probability of detection (POD) statistical model. RESULTS: The dLPODC values with 95% confidence interval for the GENE-UP Salmonella method, with either alternative or traditional confirmation, were: 0.00 (-0.03, 0.03), -0.02 (-0.15, 0.12), and 0.02 (-0.03, 0.09) for the non-inoculated, low, and high contamination levels respectively. CONCLUSIONS: The dLPODC results demonstrate no difference in performance between the candidate method and reference method for the matrix evaluated. HIGHLIGHTS: The GENE-UP Salmonella method, with ASAP and CHROMID Salmonella, provides industry with a simplified, rapid, and accurate workflow for the detection of Salmonella in a broad range of foods and select environmental surfaces.

Evaluation of the GENE-UP® Listeria monocytogenes Method for the Detection of Listeria monocytogenes in a Variety of Foods and Select Environmental Surfaces: Collaborative Study, First Action 2019.11.

BACKGROUND: The GENE-UP®  Listeria monocytogenes 2 (LMO 2) assay (Performance Tested MethodSM 121804) uses real-time PCR technology and a proprietary detection platform, the GENE-UP Thermocycler, to detect Listeria monocytogenes in a variety of foods and environmental surfaces. OBJECTIVE: The purpose of this validation was to evaluate the method's interlaboratory performance and submit the result to AOAC INTERNATIONAL for adoption as First Action Official MethodSM for the detection of Listeria monocytogenes in a variety of foods and select environmental surfaces. METHOD: The GENE-UP method was evaluated in a multi-laboratory study as part of the AFNOR NF VALIDATION certification process using unpaired test portions for one food matrix, full-cream goat milk cottage cheese (8.4% fat). The candidate method was compared to the ISO 11290-1/Amd.1:2004 reference method. Sixteen participants from 15 laboratories throughout the European Union participated. Three levels of contamination were evaluated: a non-inoculated control level (0 CFU/test portion), a low inoculum level (∼2 CFU/test portion), and a high inoculum level (∼10 CFU/test portion). Data from the study were analyzed according to the Probability of Detection (POD) statistical model as presented in the AOAC validation guidelines. RESULTS: The dLPODC values with 95% confidence interval for each comparison were; -0.02 (-0.07, 0.03), -0.08 (-0.31, 0.16), and 0.00 (-0.03, 0.03) for the non-inoculated, low, and high contamination levels, respectively. CONCLUSIONS: The dLPODC results demonstrate no difference in performance between the candidate method and reference method for the matrix evaluated. HIGHLIGHTS: The GENE-UP LMO method demonstrated accuracy and precision in detecting and discerning L. monocytogenes from other Listeria species.

Evaluation of the GENE-UP® Listeria spp. Method for the Detection of Listeria Species in a Variety of Foods and Select Environmental Surfaces: Collaborative Study, First Action 2019.10.

BACKGROUND: The GENE-UP®  Listeria spp. 2 (LIS 2) assay (Performance Tested MethodSM 121803) is a real-time PCR molecular detection method for the rapid detection of Listeria species (Listeria monocytogenes, L. innocua, L. ivanovii, L. seeligeri, and L. welshimeri) in a variety of foods and environmental surfaces. OBJECTIVE: The purpose of this validation was to evaluate the method's interlaboratory performance and submit the results to AOAC INTERNATIONAL for adoption as First Action Official MethodSM for the detection of Listeria species in a variety of foods and select environmental surfaces. METHOD: The GENE-UP method was evaluated in a multi-laboratory study as part of the AFNOR NF VALIDATION certification process using unpaired test portions for one food matrix, full-cream goat milk cottage cheese (8.4% fat). The candidate method was compared to the ISO 11290-1/Amd.1 reference method. Sixteen participants from 15 laboratories throughout the European Union participated. Three levels of contamination were evaluated: a non-inoculated control level (0 CFU/test portion), a low contamination level (∼2 CFU/test portion), and a high contamination level (∼10 CFU/test portion). Data from that study were analyzed according to the probability of detection (POD) statistical model. RESULTS: The dLPODC values with 95% confidence intervals between the candidate and reference method results were -0.02 (-0.07, 0.03), -0.08 (-0.31, 0.16), and 0.00 (-0.03, 0.03) for the non-inoculated, low, and high contamination levels, respectively. CONCLUSIONS: The dLPODC results demonstrate no difference in performance between the candidate method and reference method for the matrix evaluated. HIGHLIGHTS: Data from a singular collaborative study was used to achieve adoption as an AOAC First Action Official Method for the detection of Listeria species in a variety of foods and select environmental surfaces.

Institution of Just Culture Physician Peer Review in an Academic Medical Center.

OBJECTIVES: For academic medical centers to improve quality outcomes, identification and optimization of opportunities for improvement are necessary. Effective clinical peer review frequently has limitations on timeliness, transparency, and consideration of system processes related to untoward clinical outcomes. We developed a process to overcome these barriers and capture opportunities for process improvement identified within the clinical peer review system. METHODS: A multidisciplinary committee was formed to evaluate the current process of physician peer review at Magee Womens Hospital of the University of Pittsburgh Medical Center. Evaluation of current peer review triggers, processes, communication, transparency, and actionable outcomes was performed. A new approach was established that incorporated a protected electronic portal to improve communication and provider engagement, as well as initiation of a Just Culture peer review algorithm to realize opportunities for system improvements. RESULTS: The new process has been operative for 2 years. After initiation, the average time necessary for full case review decreased by 66% (6-2 months). Provider engagement and input have increased to 71%, from less than 10% before implementation. Most cases (51%) were identified as having more than one causative factor, with systems issues being the most frequent contributor to untoward outcomes. CONCLUSIONS: Given the recognized benefits, this approach is being considered for implementation on a broader scale within service-line quality initiatives across the University of Pittsburgh Medical Center health system. Although first implemented among faculty, consideration of incorporation into graduate medical education programs is ongoing.

Evaluation of the GENE-UP ®E. coli O157:H7 Method for the Detection of E. coli O157:H7 in Select Foods: Collaborative Study, 2019.03.

BACKGROUND: The GENE-UP®E. coli O157:H7 2 (ECO 2) assay (Performance Tested MethodSM 121805) incorporates Fluorescence Resonance Energy Transfer hybridization probes into its proprietary PCR technology for the rapid detection of E. coli O157:H7 in select foods. OBJECTIVE: The purpose of this validation was to evaluate the method's interlaboratory performance and submit the result to AOAC INTERNATIONAL for adoption as First Action Official MethodSM for the detection of E. coli O157:H7 in select foods. METHOD: The GENE-UP® method was evaluated in a multi-laboratory study as part of the MicroVal validation process using unpaired test portions for one food matrix, raw milk cheese (Comté, 34% fat, 0.8% salt). The candidate method was compared to the ISO 16654:2001 reference method. Fourteen participants from 13 laboratories throughout the European Union participated. Three levels of contamination were evaluated: a non-inoculated control level (0 colony-forming units (CFU)/test portion), a low contamination level (∼5 CFU/test portion), and a high contamination level (∼10 CFU/test portion). Data from that study were analyzed according to the Probability of Detection (POD) statistical model as presented in the AOAC validation guidelines. The difference in laboratory POD (dLPODC) values with 95% confidence interval across collaborators was calculated for each level between the candidate and reference method results, and between the candidate presumptive and confirmed results. RESULTS: The dLPODC values with 95% confidence interval were; 0.00 (-0.04, 0.04), 0.27 (0.04, 0.49), and 0.17 (0.01, 0.33) for the non-inoculated, low and high contamination levels respectively. CONCLUSIONS: The dLPODC results indicate a significant difference between the candidate method and the reference method for both the low and high contamination levels, with the candidate method producing higher recovery of the target organism at both levels. HIGHLIGHTS: The GENE-UP E. coli O157:H7 assay provides industry with a rapid, accurate detection method for E. coli O157:H7 in a broad range of foods.

The Effects of Treatment with N-Acetyl Cysteine on Clinical Signs in Persistent Breeding-Induced Endometritis Susceptible Mares.

Persistent breeding-induced endometritis (PBIE) is a major cause of infertility in mares. Endometrial inflammation that persists until embryonic descent ultimately results in early embryonic death. A poor endometrial biopsy grade (IIb or III) has been identified as a risk factor for PBIE. Intrauterine fluid accumulation (>2 cm in depth), pathologic endometrial edema, and elevated intrauterine neutrophil levels are all clinical features of PBIE. Commonly applied treatment options include uterine lavage and oxytocin therapy. N-acetyl cysteine (NAC), a mucolytic used to treat bacterial endometritis in mares, has anti-inflammatory properties and was investigated as a potential treatment for PBIE. A randomized, blinded, cross-over design clinical trial used NAC before breeding in PBIE-susceptible mares (n = 9). Intrauterine infusion of 3.3% NAC was performed 12 hours before insemination, and endometrial cytology and endometrial biopsy samples were obtained at 12 and 60 hours after insemination. Endometrial biopsies were evaluated for the degree of inflammation present. Clinical signs of endometrial edema and intrauterine fluid volumes were assessed by transrectal ultrasound at 12 and then every 24 hours after breeding. Data were analyzed using repeated measures analysis of variance and a Mann Whitney Wilcoxon Test. Treatment with NAC did not improve clinical signs in PBIE-affected mares. However, endometrial biopsies from mares treated with NAC displayed more diffuse and severe neutrophil infiltration than control cycles. Further research using a larger population of mares is required to evaluate the effects of NAC treatment on the endometrium of PBIE-susceptible mares.