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Machine learning (ML) holds great promise in transforming healthcare. While published studies have shown the utility of ML models in interpreting medical imaging examinations, these are often evaluated under laboratory settings. The importance of real world evaluation is best illustrated by case studies that have documented successes and failures in the translation of these models into clinical environments. A key prerequisite for the clinical adoption of these technologies is demonstrating generalizable ML model performance under real world circumstances. The purpose of this study was to demonstrate that ML model generalizability is achievable in medical imaging with the detection of intracranial hemorrhage (ICH) on non-contrast computed tomography (CT) scans serving as the use case. An ML model was trained using 21,784 scans from the RSNA Intracranial Hemorrhage CT dataset while generalizability was evaluated using an external validation dataset obtained from our busy trauma and neurosurgical center. This real world external validation dataset consisted of every unenhanced head CT scan (n = 5965) performed in our emergency department in 2019 without exclusion. The model demonstrated an AUC of 98.4%, sensitivity of 98.8%, and specificity of 98.0%, on the test dataset. On external validation, the model demonstrated an AUC of 95.4%, sensitivity of 91.3%, and specificity of 94.1%. Evaluating the ML model using a real world external validation dataset that is temporally and geographically distinct from the training dataset indicates that ML generalizability is achievable in medical imaging applications.

Autism spectrum disorder (ASD) is a group of heterogeneous, behaviorally defined neurodevelopmental conditions influenced by both genetic and environmental factors. Here, we show that supplementation of multiple low-dose nutrients-an important environmental factor contributing to ASD-can modulate synaptic proteomes, reconfigure neural ensembles, and improve social behaviors in mice. First, we used Tbr1+/- mice, a well-established model of ASD, to investigate the effect of nutrient cocktails containing zinc, branched-chain amino acids (BCAA), and serine, all of which are known to regulate synapse formation and activity. Supplementation of nutrient cocktails for 7 days altered total proteomes by increasing synapse-related proteins. Our results further reveal that Tbr1 haploinsufficiency promotes hyperactivation and hyperconnectivity of basolateral amygdala (BLA) neurons, enhancing the activity correlation between individual neurons and their corresponding ensembles. Nutrient supplementation normalized the activity and connectivity of the BLA neurons in Tbr1+/- mice during social interactions. We further show that although a low dose of individual nutrients did not alter social behaviors, treatment with supplement mixtures containing low-dose individual nutrients improved social behaviors and associative memory of Tbr1+/- mice, implying a synergistic effect of combining low-dose zinc, BCAA, and serine. Moreover, the supplement cocktails also improved social behaviors in Nf1+/- and Cttnbp2+/M120I mice, two additional ASD mouse models. Thus, our findings reveal aberrant neural connectivity in the BLA of Tbr1+/- mice and indicate that dietary supplementation with zinc, BCAA, and/or serine offers a safe and accessible approach to mitigate neural connectivity and social behaviors across multiple ASD models.

Background Chronic rhinosinusitis (CRS) is diagnosed with symptoms and objective endoscopy or computed tomography (CT). The Lund–Mackay score (LMS) is often used to determine the radiologic severity of CRS and make clinical decisions. This proof-of-concept study aimed to develop an automated algorithm combining a convolutional neural network (CNN) for sinus segmentation with post-processing to compute LMS directly from CT scans. Results Radiology Information System was queried for outpatient paranasal sinus CTs at a tertiary institution. We identified 1,399 CT scans which were manually labelled with LMS of individual sinuses. Seventy-seven CT scans with 13,668 coronal images were segmented manually for individual sinuses. Our model for segmentation achieved a mean Dice score of 0.85 for all sinus regions, except for the osteomeatal complex. For individual Dice scores were 0.95, 0.71, 0.78, 0.93, 0.86 for the maxillary, anterior ethmoid, posterior ethmoid, sphenoid, and frontal sinuses, respectively. LMS was computed automatically by applying adaptive image thresholding and pixel counting to the CNN’s segmented regions. A convolutional neural network (CNN) model was trained to segment each sinus region. Overall, the LMS model showed a high degree of accuracy with a score of 0.92, 0.99, 0.99, 0.97, 0.99, 0.86 for the maxillary, anterior ethmoid, posterior ethmoid, sphenoid, and frontal sinuses, respectively. Conclusions Reporting of paranasal sinus CT can be automated and potentially standardized with a CNN model to provide accurate Lund–Mackay score.

Docetaxel and cabazitaxel are taxane chemotherapy treatments for metastatic castration-resistant prostate cancer (CRPC). However, therapeutic resistance remains a major issue. MicroRNAs are short non-coding RNAs that can silence multiple genes, regulating several signalling pathways simultaneously. Therefore, synthetic microRNAs may have therapeutic potential in CRPC by regulating genes involved in taxane response and minimise compensatory mechanisms that cause taxane resistance. To identify microRNAs that can improve the efficacy of taxanes in CRPC, we performed a genome-wide screen of 1280 microRNAs in the CRPC cell lines PC3 and DU145 in combination with docetaxel or cabazitaxel treatment. Mimics of miR-217 and miR-181b-5p enhanced apoptosis significantly in PC3 cells in the presence of these taxanes. These mimics downregulated at least a thousand different transcripts, which were enriched for genes with cell proliferation and focal adhesion functions. Individual knockdown of a selection of 46 genes representing these transcripts resulted in toxic or taxane sensitisation effects, indicating that these genes may be mediating the effects of the microRNA mimics. A range of these genes are expressed in CRPC metastases, suggesting that these microRNA mimics may be functional in CRPC. With further development, these microRNA mimics may have therapeutic potential to improve taxane response in CRPC patients.

BACKGROUNDMetastatic hormone-sensitive prostate cancer (mHSPC) is androgen dependent, and its treatment includes androgen deprivation therapy (ADT) with gonadal testosterone suppression. Since 2014, overall survival (OS) has been prolonged with addition of other systemic therapies, such as adrenal androgen synthesis blockers, potent androgen receptor blockers, or docetaxel, to ADT. HSD3B1 encodes the rate-limiting enzyme for nongonadal androgen synthesis, 3β-hydroxysteroid dehydrogenase-1, and has a common adrenal-permissive missense-encoding variant that confers increased synthesis of potent androgens from nongonadal precursor steroids and poorer prostate cancer outcomes.METHODSOur prespecified hypothesis was that poor outcome associated with inheritance of the adrenal-permissive HSD3B1 allele with ADT alone is reversed in patients with low-volume (LV) mHSPC with up-front ADT plus addition of androgen receptor (AR) antagonists to inhibit the effect of adrenal androgens. HSD3B1 genotype was obtained in 287 patients with LV disease treated with ADT + AR antagonist only in the phase III Enzalutamide in First Line Androgen Deprivation Therapy for Metastatic Prostate Cancer (ENZAMET) trial and was associated with clinical outcomes.RESULTSPatients who inherited the adrenal-permissive HSD3B1 allele had more favorable 5-year clinical progression-free survival and OS when treated with ADT plus enzalutamide or ADT plus nonsteroidal antiandrogen compared with their counterparts who did not have adrenal-permissive HSD3B1 inheritance. HSD3B1 was also associated with OS after accounting for known clinical variables. Patients with both genotypes benefited from early enzalutamide.CONCLUSIONThese data demonstrated an inherited physiologic driver of prostate cancer mortality is associated with clinical outcomes and is potentially pharmacologically reversible.FUNDINGNational Cancer Institute, NIH; Department of Defense; Prostate Cancer Foundation, Australian National Health and Medical Research Council.

Prostate cancer is a complex and heterogeneous disease, but a small number of cell lines have dominated basic prostate cancer research, representing a major obstacle in the field of drug and biomarker discovery. A growing lack of confidence in cell lines has seen a shift toward more sophisticated pre-clinical cancer models that incorporate patient-derived tumors as xenografts or explants, to more accurately reflect clinical disease. Not only do these models retain critical features of the original tumor, and account for the molecular diversity and cellular heterogeneity of prostate cancer, but they provide a unique opportunity to conduct research in matched tumor samples. The challenge that accompanies these complex tissue models is increased complexity of analysis. With over 10 years of experience working with patient-derived explants (PDEs) of prostate cancer, this study provides guidance on the PDE method, its limitations, and considerations for addressing the heterogeneity of prostate cancer PDEs that are based on statistical modeling. Using inhibitors of the molecular chaperone heat shock protein 90 (Hsp90) as an example of a drug that induces robust proliferative response, we demonstrate how multi-omics analysis in prostate cancer PDEs is both feasible and essential for identification of key biological pathways, with significant potential for novel drug target and biomarker discovery.

Background: Biomarkers of therapeutic response and prognosis are needed to assist in the sequencing of treatments for metastatic castration-resistant prostate cancer (CRPC). Previously in a Phase 1 discovery study, we identified 14 circulating microRNAs that were associated with response to docetaxel chemotherapy or overall survival. We performed a Phase 2 validation study to verify these findings. Methods: Using real-time PCR, the levels of the 14 microRNAs were measured in plasma collected before and after the first cycle of docetaxel from a Phase 2 cohort of 89 patients. Results: The microRNAs were not associated with docetaxel response in the Phase 2 cohort. Higher baseline levels of six microRNAs, predominantly of the miR-200 family, were confirmed to be associated with shorter overall survival. A microRNA signature comprising these six microRNAs predicted high-risk patients in the Phase 2 cohort with a hazard ratio of 4.12 (95% CI 2.20–7.70, P =0.000001). The signature was an independent predictor in multivariable analysis with clinicopathological factors. Conclusions: The association of circulating microRNAs with overall survival suggests their involvement in CRPC progression.

BackgroundDysregulated lipid metabolism is associated with more aggressive pathology and poorer prognosis in prostate cancer (PC). The primary aim of the study is to assess the relationship between the plasma lipidome and clinical outcomes in localised and metastatic PC. The secondary aim is to validate a prognostic circulating 3-lipid signature specific to metastatic castration-resistant PC (mCRPC).Patients and methodsComprehensive lipidomic analysis was performed on pre-treatment plasma samples from men with localised PC (N = 389), metastatic hormone-sensitive PC (mHSPC)(N = 44), or mCRPC (validation cohort, N = 137). Clinical outcomes from our previously published mCRPC cohort (N = 159) that was used to derive the prognostic circulating 3-lipid signature, were updated. Associations between circulating lipids and clinical outcomes were examined by Cox regression and latent class analysis.ResultsCirculating lipid profiles featuring elevated levels of ceramide species were associated with metastatic relapse in localised PC (HR 5.80, 95% CI 3.04–11.1, P = 1 × 10−6), earlier testosterone suppression failure in mHSPC (HR 3.70, 95% CI 1.37–10.0, P = 0.01), and shorter overall survival in mCRPC (HR 2.54, 95% CI 1.73–3.72, P = 1 × 10−6). The prognostic significance of circulating lipid profiles in localised PC was independent of standard clinicopathological and metabolic factors (P < 0.0002). The 3-lipid signature was verified in the mCRPC validation cohort (HR 2.39, 95% CI 1.63–3.51, P = 1 × 10−5).ConclusionsElevated circulating ceramide species are associated with poorer clinical outcomes across the natural history of PC. These clinically actionable lipid profiles could be therapeutically targeted in prospective clinical trials to potentially improve PC outcomes.

Background Clinical decision-making is considered an essential behaviour in clinical practice. However, no research has been done to examine the associations among midwives’ clinical decision-making, work environment and psychological empowerment. Thus, this study aimed to determine the influence of work environment on midwives’ clinical decision-making and confirm the mediating role of psychological empowerment. Method This study was designed as a multicentre cross-sectional study, and included 602 registered midwives from 25 public hospitals in China. A sociodemographic questionnaire, Work Environment Scale, Psychological Empowerment Scale and Clinical decision-making Scale were applied. A structural equation model was conducted to estimate the hypothesis model of the clinical decision-making among midwives and explore the potential mediating mechanism of midwives’ clinical decision-making. This model was employed maximum likelihood estimation method and bootstrapping to examine the statistical significance. Results The mean score of clinical decision-making among midwives was 143.03 ± 14.22, at an intermediate level. The data of this hypothesis model fitted well, and the results showed that work environment positively affected psychological empowerment, which in turn positively affected clinical decision-making; psychological empowerment partly mediated the relationship between work environment and clinical decision-making among midwives. Conclusions Midwives’ clinical decision-making could be promoted directly or indirectly by providing a healthy work environment and improving psychological empowerment. It is essential for hospital managers to pay attention to the assessment of the midwives’ work environment and actively improve it, such as establishing a supportive, fair and just workplace, and maintaining effective communication with midwives. Furthermore, managers can also promote midwives’ clinical decision-making behaviour by enhancing their psychological empowerment via enhancing job autonomy.

Background: Despite advances in the treatment of metastatic castration-resistant prostate cancer (mCRPC), primary and secondary resistance to current therapies remains. Elevated circulating sphingolipids are associated with poor outcomes in patients with mCRPC, including therapeutic resistance and shorter overall survival. PCPro is a clinically accessible, regulatory compliant plasma lipid biomarker of poor prognosis in mCRPC, which incorporates prognostic sphingolipids. We hypothesize that reversal of the PCPro signature in men with mCRPC by sphingolipid-lowering agents will improve their clinical outcomes. However, the first step is to determine whether this poor prognostic lipid signature can be modulated. A potential sphingolipid-lowering agent is the PCSK9-inhibitor evolocumab, which is used in the management of hypercholesterolemia. Objectives: Our primary objective is to assess whether treatment with evolocumab during standard anticancer therapy can safely modify the PCPro signature in men with mCRPC. Design: This is a multicenter, open label phase II trial. Methods: Men with mCRPC commencing docetaxel, cabazitaxel, abiraterone, enzalutamide, olaparib, or lutetium-177 PSMA for disease progression will be screened for the presence of PCPro. Those who are PCPro positive will receive a 12-week course of evolocumab concurrent with their standard therapy. Dosage is as per cardiovascular guidelines (420 mg subcutaneously every 4 weeks). PCPro will be repeated after 12 weeks. The primary endpoint is reversal of PCPro. The secondary endpoint is the safety of combination therapy with exploratory endpoints characterizing changes in comprehensive lipid profiles pre- and post-treatment. Discussion: This study will evaluate whether evolocumab can safely modify the PCPro signature in men with mCRPC, providing essential data to the development of precision metabolic therapy in the management of prostate cancer. Trial registration: This study is approved by the Human Research Ethics Committee (X22-0072 and 2022/ETH00427). It is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12622001003763).