Rarely,scientific developments centered around the patient as a whole arepublished.Our multidisciplinary group,headed by gastrointestinal surgeons,applied this research philosophy considering the most important aspect...Rarely,scientific developments centered around the patient as a whole arepublished.Our multidisciplinary group,headed by gastrointestinal surgeons,applied this research philosophy considering the most important aspects of thediseases“colon-and rectal cancer”in the long-term developments.Good expertcooperation/knowledge at the Comprehensive Cancer Center Ulm(CCCU)wereapplied in several phase III trials for multimodal treatments of primary tumors(MMT)and metastatic diseases(involving nearly 2000 patients and 64 centers),fortreatment individualization of MMT and of metastatic disease,for psychooncology/quality of life involving the patients’wishes,and for disease prevention.Most of the targets initially were heavily rejected/discussed in thescientific communities,but now have become standards in treatments andnational guidelines or are topics in modern translational research protocolsinvolving molecular biology for e.g.,“patient centered individualized treatment”.In this context we also describe the paths we had to tread in order to realize ournew goals,which at the end were highly beneficial for the patients from manypoints of view.This description is also important for students and youngresearchers who,with an actual view on our recent developments,might want toknow how medical progress was achieved.展开更多
Acute myeloid leukemia(AML)remains a biologically heterogeneous disease with historically limited targeted therapies and poor outcomes.The development of menin inhibitors represents a promising shift,particularly for ...Acute myeloid leukemia(AML)remains a biologically heterogeneous disease with historically limited targeted therapies and poor outcomes.The development of menin inhibitors represents a promising shift,particularly for patients harboring KMT2A rearrangements(KMT2Ar)and NPM1 mutations(NPM1m).This manuscript reviews the molecular rationale of menin inhibition for aberrant homeobox/myeloid ectopic insertion site 1(HOX/MEIS1)-driven gene expression and leukemogenesis,clinical trial outcomes,and safety data for menin inhibitors,with a focus on recently FDA-approved revumenib and several other agents in development,ziftomenib(KO-539),bleximenib(JNJ-75276617),and icovamenib(BMF-219).We also focused our discussion on future directions to include resistance mechanisms,biomarker identification and monitoring strategies,and combination therapies.Menin inhibition is now being clinically integrated into relapsed/refractory and frontline treatment settings.展开更多
Nonhomologous DNA end joining （NHEJ） is the primary pathway for repair of double-strand DNA breaks in human cells and in multicellular eukaryotes. The causes of double-strand breaks often fragment the DNA at the sit...Nonhomologous DNA end joining （NHEJ） is the primary pathway for repair of double-strand DNA breaks in human cells and in multicellular eukaryotes. The causes of double-strand breaks often fragment the DNA at the site of damage, resulting in the loss of information there. NHEJ does not restore the lost information and may resect additional nucleotides during the repair process. The ability to repair a wide range of overhang and damage configurations reflects the flexibility of the nuclease, polymerases, and ligase of NHEJ. The flexibility of the individual components also explains the large number of ways in which NHEJ can repair any given pair of DNA ends. The loss of information locally at sites of NHEJ repair may contribute to cancer and aging, but the action by NHEJ ensures that entire segments of chromosomes are not lost.展开更多
Currently the clinical management of breast cancer relies on relatively few prognostic/predictive clinical markers(estrogen receptor, progesterone receptor, HER2), based on primary tumor biology. Circulating biomarker...Currently the clinical management of breast cancer relies on relatively few prognostic/predictive clinical markers(estrogen receptor, progesterone receptor, HER2), based on primary tumor biology. Circulating biomarkers, such as circulating tumor DNA(ctDNA) or circulating tumor cells(CTCs) may enhance our treatment options by focusing on the very cells that are the direct precursors of distant metastatic disease, and probably inherently different than the primary tumor's biology. To shift the current clinical paradigm, assessing tumor biology in real time by molecularly profiling CTCs or ctDNA may serve to discover therapeutic targets, detect minimal residual disease and predict response to treatment. This review serves to elucidate the detection,characterization, and clinical application of CTCs and ctDNA with the goal of precision treatment of breast cancer.展开更多
Bone metastases are the main driver of morbidity and mortality in advanced prostate cancer. Targeting the bone microenvironment, a key player in the pathogenesis of bone metastasis, has become one of the mainstays of ...Bone metastases are the main driver of morbidity and mortality in advanced prostate cancer. Targeting the bone microenvironment, a key player in the pathogenesis of bone metastasis, has become one of the mainstays of therapy in men with advanced prostate cancer. This review will evaluate the data supporting the use of bone-targeted therapy, including （1） bisphosphonates such as zoledronic acid, which directly target osteoclasts, （2） denosumab, a receptor activator of nuclear factor-kappa B （RANK） ligand inhibitor, which targets a key component of bone stromal interaction, and （3） radium-223, an alpha-emitting calcium mimetic, which hones to the metabolically active areas of osteoblastic metastasis and induces double-strand breaks in the DNA. Denosumab has shown enhanced delay in skeletal-related events compared to zoledronic acid in patients with metastatic castration-resistant prostate cancer （mCRPC）. Data are mixed with regard to pain control as a primary measure of efficacy. New data call into question dosing frequency, with quarterly dosing strategy potentially achieving similar effect compared to monthly dosing for zoledronic acid. In the case of radium-223, there are data for both pain palliation and improved overall survival in mCRPC. Further studies are needed to optimize timing and combination strategies for bone-targeted therapies. Ongoing studies will explore the impact of combining bone-targeted therapy with investigational therapeutic agents such as immunotherapy, for advanced prostate cancer. Future studies should strive to develop biomarkers of response, in order to improve efficacy and cost-effectiveness of these agents.展开更多
MicroRNAs(miRNAs)are small noncoding RNAs involved in the regulation of mRNA transcription and translation,and possess all desirable features of an ideal tumor marker.Of almost 31 different miRNA clusters identified i...MicroRNAs(miRNAs)are small noncoding RNAs involved in the regulation of mRNA transcription and translation,and possess all desirable features of an ideal tumor marker.Of almost 31 different miRNA clusters identified in germ cell tumors(GCTs),miR-371a-3p has shown exceptionally high sensitivity and specificity for both seminomatous and nonseminomatous GCTs.It is easily obtainable and correlates well with tumor burden.Recent multiinstitutional prospective studies have shown promising test characteristics for miR-371a-3p as a diagnostic blood-based biomarker for GCT prior to orchiectomy including 80%e100%sensitivity and 90%e100%specificity.This accuracy may address other unmet needs in the management of patients with GCT.Early studies have suggested the utility of miR-371a-3p in detecting occult nodal metastasis in high-risk clinical stage I and early stage II disease.Ongoing clinical trials including SWOG 1823 and AGCT1531 are specifically designed to confirm the utility of miR-371a-3p in clinical stage I GCT.Despite its strong association with viable GCT after treatment with chemotherapy,miR-371a-3p does not seem to accurately predict the presence of teratoma in residual lesions.Also,standardization of extraction and interpretation methods is a necessary step to assure uniform results across different institutions.展开更多
Objective:Radical nephroureterectomy(RNU)is considered the standard of care for patients with high-risk upper tract urothelial carcinoma.Current literature reveals a deficit in direct comparative studies evaluating th...Objective:Radical nephroureterectomy(RNU)is considered the standard of care for patients with high-risk upper tract urothelial carcinoma.Current literature reveals a deficit in direct comparative studies evaluating the efficacy of different chemotherapeutic agents administered in single postoperative instillation following RNU.The primary aim of this study was to compare the bladder recurrence(BR)rates between patients receiving a single instillation of mitomycin C(MMC)versus gemcitabine(Gem)after RNU.Methods:The ROBUUST(ROBotic surgery for Upper tract Urothelial cancer STudy)2.0 is an international,multicenter registry that aggregates data on patients who have undergone curative surgery for upper tract urothelial carcinoma across participating centers from January 2015 to December 2022.Data including primary baseline variables of the patients,characteristics of the tumors,surgical management,and definitive histopathological characterizations were collected and stratified based on the type of postoperative bladder instillation:MMC(the MMC group)and Gem(the Gem group).We selected variables correlated with our primary outcome to conduct a propensity-score match analysis.Results:One hundred patients in the MMC group were matched 1:1 with 100 patients in the Gem group.At 36 months of follow-up,30 patients in the MMC group and 39 patients in the Gem group experienced BR,representing recurrence rates of 30%and 39%,respectively(p=0.2).The Cox proportional hazards model comparing BR between the groups revealed a hazard ratio of 1.58(95%confidence interval:0.98-2.55)with a non-statistically significant increased risk of BR in the Gem group compared with the MMC group(p=0.059).Conclusion:A single perioperative instillation of Gem or MMC seems to offer similar efficacy in reducing the risk of BR in patients undergoing RNU.Further research,ideally within the framework of prospective studies,is warranted to elucidate the optimal chemotherapeutic approach in this setting.展开更多
Coronavirus disease 2019(COVID-19),caused by severe acute respiratory syndrome coronavirus 2,has spread globally and threatens public health.Advanced in vitro models that recapitulate the architecture and functioning ...Coronavirus disease 2019(COVID-19),caused by severe acute respiratory syndrome coronavirus 2,has spread globally and threatens public health.Advanced in vitro models that recapitulate the architecture and functioning of specific tissues and organs are in high demand for COVID-19-related pathology studies and drug screening.Since three-dimensional in vitro cultures,such as self-assembled and engineered organoid cultures,surpass conventional two-dimensional cultures and animal models with respect to increased cellular complexity,an environment more relevant to humans,and reduced cost,they are promising platforms for understanding viral pathogenesis and developing new therapeutics.This review highlights the recent advances in self-assembled and engineered organoid technologies that are used for COVID-19 studies.The challenges and future perspectives are also discussed.展开更多
IκB kinase ε(IKKε) is a non-canonical IκB kinase that is extensively studied in the context of innate immune response. Recently, significant progress has been made in understanding the role of IKKεin interferon(I...IκB kinase ε(IKKε) is a non-canonical IκB kinase that is extensively studied in the context of innate immune response. Recently, significant progress has been made in understanding the role of IKKεin interferon(IFN) signaling. In addition to its roles in innate immunity, recent studies also demonstrate that IKKε is a key regulator of the adaptive immune response. Specifically, IKKεfunctions as a negative feedback kinase to curtail CD8 T cell response, implying that it can be a potential therapeutic target to boost antiviral and antitumor T cell immunity. In this review, we highlight the roles of IKKε in regulating IFN signaling and T cell immunity, and discuss a few imminent questions that remain to be answered.展开更多
Cancer metabolism plays an essential role in therapeutic resistance,where significant inter-and intra-tumoral heterogeneity exists.Hypoxia is a prominent driver of metabolic rewiring behaviors and drug responses.Reca-...Cancer metabolism plays an essential role in therapeutic resistance,where significant inter-and intra-tumoral heterogeneity exists.Hypoxia is a prominent driver of metabolic rewiring behaviors and drug responses.Reca-pitulating the hypoxic landscape in the tumor microenvironment thus offers unique insights into heterogeneity in metabolic rewiring and therapeutic responses,to inform better treatment strategies.There remains a lack of scalable tools that can readily interface with imaging platforms and resolve the heterogeneous behaviors in hypoxia-associated metabolic rewiring.Here we present a micro-metabolic rewiring(μMeRe)assay that provides the scalability and resolution needed to characterize the metabolic rewiring behaviors of different cancer cells in the context of hypoxic solid tumors.Our assay generates hypoxia through cellular metabolism without external gas controls,enabling the characterization of cell-specific intrinsic ability to drive hypoxia and undergo meta-bolic rewiring.We further developed quantitative metrics that measure the metabolic plasticity through phe-notypes and gene expression.As a proof-of-concept,we evaluated the efficacy of a metabolism-targeting strategy in mitigating hypoxia-and metabolic rewiring-induced chemotherapeutic resistance.Our study and the scalable platform thus lay the foundation for designing more effective cancer treatments tailored toward specific meta-bolic rewiring behaviors.展开更多
Cancer progression is marked by the infiltration of immunosuppressive cells,such as tumor-associated macrophages(TAMs),regulatory T lymphocytes(Tregs),and myeloid-derived suppressor cells(MDSCs).These cells play a key...Cancer progression is marked by the infiltration of immunosuppressive cells,such as tumor-associated macrophages(TAMs),regulatory T lymphocytes(Tregs),and myeloid-derived suppressor cells(MDSCs).These cells play a key role in abrogating the cytotoxic T lymphocyte-mediated(CTL)immune response,allowing tumor growth to proceed unabated.Furthermore,targeting these immunosuppressive cells through the use of peptides and peptide-based nanomedicine has shown promising results.Here we review the origins and functions of immunosuppressive cells in cancer progression,peptide-based systems used in their targeting,and explore future avenues of research regarding cancer immunotherapy.The success of these studies demonstrates the importance of the tumor immune microenvironment in the propagation of cancer and the potential of peptide-based nanomaterials as immunomodulatory agents.展开更多
Anaplastic lymphoma kinase(ALK)gene rearrangements have been identified as potent oncogenic drivers in several malignancies,including non-small cell lung cancer(NSCLC).The discovery of ALK inhibition using a tyrosine ...Anaplastic lymphoma kinase(ALK)gene rearrangements have been identified as potent oncogenic drivers in several malignancies,including non-small cell lung cancer(NSCLC).The discovery of ALK inhibition using a tyrosine kinase inhibitor(TKI)has dramatically improved the outcomes of patients with ALK-mutated NSCLC.However,the emergence of intrinsic and acquired resistance inevitably occurs with ALK TKI use.This review describes the molecular mechanisms of ALK TKI resistance and discusses management strategies to overcome therapeutic resistance.展开更多
The treatment scenario of colorectal cancer(CRC)has been evolving in recent years with the introduction of novel targeted agents and new therapeutic strategies for the metastatic disease.An extensive effort has been d...The treatment scenario of colorectal cancer(CRC)has been evolving in recent years with the introduction of novel targeted agents and new therapeutic strategies for the metastatic disease.An extensive effort has been directed to the identification of predictive biomarkers to aid patients selection and guide therapeutic choices.Pharmacogenomics represents an irreplaceable tool to individualize patients treatment based on germline and tumor acquired somatic genetic variations able to predict drugs response and risk of toxicities.The growing knowledge of CRC molecular characteristics and complex genomic makeup has played a crucial role in identifying predictive pharmacogenomic biomarkers,while supporting the rationale for the development of new drugs and treatment combinations.Clinical validation of promising biomarkers,however,is often an issue.More recently,a deeper understanding of resistance mechanisms and tumor escape dynamics under treatment pressure and the availability of novel technologies are opening new perspectives in this field.This review aims to present an overview of current pharmacogenomic biomarkers and future perspectives of pharmacogenomics in CRC,in an evolving scenario moving from a single drug-gene interactions approach to a more comprehensive genome-wide approach,comprising genomics and epigenetics.展开更多
Background:DNA methylation and gene expression are known to play important roles in the etiology of human diseases such as prostate cancer(PCa).However,it has not yet been possible to incorporate information of DNA me...Background:DNA methylation and gene expression are known to play important roles in the etiology of human diseases such as prostate cancer(PCa).However,it has not yet been possible to incorporate information of DNA methylation and gene expression into polygenic risk scores(PRSs).Here,we aimed to develop and validate an improved PRS for PCa risk by incorporating genetically predicted gene expression and DNA methylation,and other genomic information using an integrative method.Methods:Using data from the PRACTICAL consortium,we derived multiple sets of genetic scores,including those based on available single-nucleotide polymorphisms through widely used methods of pruning and thresholding,LDpred,LDpred-funt,AnnoPred,and EBPRS,as well as PRS constructed using the genetically predicted gene expression and DNA methylation through a revised pruning and thresholding strategy.In the tuning step,using the UK Biobank data(1458 prevalent cases and 1467 controls),we selected PRSs with the best performance.Using an independent set of data from the UK Biobank,we developed an integrative PRS combining information from individual scores.Furthermore,in the testing step,we tested the performance of the integrative PRS in another independent set of UK Biobank data of incident cases and controls.Results:Our constructed PRS had improved performance(C statistics:76.1%)over PRSs constructed by individual benchmark methods(from 69.6%to 74.7%).Furthermore,our new PRS had much higher risk assessment power than family history.The overall net reclassification improvement was 69.0%by adding PRS to the baseline model compared with 12.5%by adding family history.Conclusions:We developed and validated a new PRS which may improve the utility in predicting the risk of developing PCa.Our innovative method can also be applied to other human diseases to improve risk prediction across multiple outcomes.展开更多
One in three Americans is at risk for developing chronic kidney disease （CKD） and end-stage renal disease （ESRD）, leading to the need for dialysis or a kidney transplant. Small-molecule drugs have been proposed as...One in three Americans is at risk for developing chronic kidney disease （CKD） and end-stage renal disease （ESRD）, leading to the need for dialysis or a kidney transplant. Small-molecule drugs have been proposed as therapies to manage kidney diseases, but high dosages are often required to achieve therapeutic efficacy, generating off-target side effects, some of which are lethal. To address these limitations, we developed a novel kidney-targeting multimodal micelle （KM） system for drug delivery applications. SpecificaU~ we incorporated the kidney-targeting peptide （Lysine-Lysine-Glutamic acid-Glutamic acid-Glutamic acid）3-Lysine） （（KKEEE）3K） into micelles. This peptide binds to megalin, a multi-ligand cell surface receptor present on renal tubule cells. When incubated with human kidney proximal tubule cells, KMs were found to be biocompatible in vitro. In vivo, KMs showed higher accumulation in the kidneys as compared to a non-targeted （NT） control upon intravenous injection in wild-type C57BL/6J mice. Histological evaluation showed no signs of tissue damage, while blood urea nitrogen （BUN） and creatinine levels were within normal ranges, validating the preservation of kidney health upon micelle administration. To our knowledge, this is the first utilization of （KKEEE）BK in a nanoparticle formulation, and our study offers strong evidence that this novel nanoparticle platform can be used as a candidate drug delivery carrier to direct therapeutics to diseased tissue in CKD.展开更多
On October 7, 2015, the Nobel Prize Committee announced that the 2015 Nobel Prize in Chemistry had been awarded jointly to Professors Paul Modrich, Tomas Lindahl and Aziz Sancar （Figure 1）, each of whom made ground-...On October 7, 2015, the Nobel Prize Committee announced that the 2015 Nobel Prize in Chemistry had been awarded jointly to Professors Paul Modrich, Tomas Lindahl and Aziz Sancar （Figure 1）, each of whom made ground-breaking discoveries about the molecular mechanisms of DNA Re- pair. In one of life＇s unpredictable turns, Paul was among the last individuals in his entire personal, professional and social network to learn of the Committee＇s decision, be- cause Paul was very far ＂off-the-grid＂ at the time of the announcement. The news that he had been selected as a 2015 Nobel Laureate may have taken Paul by surprise, but it certainly was not a surprise to most, if not all, of Paul＇s colleagues, students, family and friends.展开更多
Aim:CD22ΔE12 as an oncogenic driver lesion in aggressive and drug-resistant B-precursor acute lymphoblastic leukemia(BPL)cells.The purpose of the present study was to identify the CD22ΔE12-specific signature transcr...Aim:CD22ΔE12 as an oncogenic driver lesion in aggressive and drug-resistant B-precursor acute lymphoblastic leukemia(BPL)cells.The purpose of the present study was to identify the CD22ΔE12-specific signature transcriptome in human BPL cells and evaluate the clinical potential of a nanoscale formulation of CD22ΔE12-siRNA as an RNAi therapeutic against drug-resistant BPL.CD22ΔE12-siRNA nanoparticles significantly improved the event-free survival(EFS)outcome of NOD/SCID(NS)mice challenged with human BPL xenograft cells.Methods:Gene expression and translational bioinformatics methods were applied to examine the expression of the CD22ΔE12-specific signature transcriptome in human BPL cells in subsets of BPL patients.Survival analysis for mice challenged with BPL cells and treated with CD22ΔE12 siRNA was performed using standard methods.Results:Leukemia cells from CD22ΔE12-Tg mice exhibit gene and protein expression profiles consistent with constitutive activation of multiple signaling networks,mimicking the profiles of relapsed BPL patients as well as newly diagnosed high-risk patients with BCR-ABL+/Philadelphia chromosome(Ph)+BPL as well as Ph-like BPL.A nanoscale formulation of CD22ΔE12-siRNA abrogated the in vivo clonogenicity of the leukemia-initiating leukemic cell fraction in xenograft specimens derived from patients with relapsed BPL and significantly improved the EFS outcome of NS mice challenged with drug-resistant human BPL xenograft cells.Conclusion:The CD22-RNAi technology is applicable to all BPL patients both high risk and standard risk.That is because CD22ΔE12 is a characteristic feature of drug-resistant leukemic clones that escape chemotherapy and cause relapse in both high risk and low risk subgroups of patients.The technology therefore has the potential(1)for prevention of relapses by selectively killing the clones that are most likely to escape chemotherapy and cause relapse as well(2)for treatment of relapses in BPL.This research project may also lead to innovative salvage regimens against other forms of CD22ΔE12-positive relapsed B-lineage leukemias and lymphomas.展开更多
Trinucleotide repeat expansions cause over 30 severe neuromuscular and neurodegenerative disorders, including Huntington's disease, myotonic dystrophy type 1, and fragile X syndrome. Although previous studies have...Trinucleotide repeat expansions cause over 30 severe neuromuscular and neurodegenerative disorders, including Huntington's disease, myotonic dystrophy type 1, and fragile X syndrome. Although previous studies have substantially advanced the understanding of the disease biology, many key features remain unknown. DNA mismatch repair(MMR) plays a critical role in genome maintenance by removing DNA mismatches generated during DNA replication. However, MMR components,particularly mismatch recognition protein MutSβ and its interacting factors MutLα and MutLγ, have been implicated in trinucleotide repeat instability. In this review, we will discuss the roles of these key MMR proteins in promoting trinucleotide repeat instability.展开更多
Importance:The diversity of pediatric genitourinary malignancies requires a timely resource detailing tumor characteristics and survival.Objective:To determine the incidence,demographics,and outcomes of all pediatric ...Importance:The diversity of pediatric genitourinary malignancies requires a timely resource detailing tumor characteristics and survival.Objective:To determine the incidence,demographics,and outcomes of all pediatric genitourinary tumors within the United States.Methods:A population-based search for patients diagnosed with genitourinary cancers under age 15 was performed using the National Cancer Institute’s Surveillance,Epidemiology,and End Results 18 registry.Information on primary tumor location,histologic type,patient age,sex,year of diagnosis,race,treatment,cause of death,and survival months was extracted.Descriptive epidemiological and survival statistics were calculated for all variables.Results:A total of 4576 cases from 1973 through 2015 were identified.The most common primary tumor sites were the kidney(80.3%),testis(12.3%),bladder(2.8%),and vagina(1.5%).Nephroblastoma(87.9%)and sarcoma(3.4%)were the most common renal malignancies.Rhabdomyosarcoma was common in the vagina,bladder,and testis at rates of 66.2%,61.2%,and 24.6%,respectively.Germ cell tumors(71.0%)were the most common primary tumor of the testis.Ten-year overall survival(OS)for renal nephroblastoma and sarcoma was 88%and 82%,respectively.Ten-year OS for RMS of the testis was 91%,the bladder was 79%,the vagina was 79%,and the prostate was 56%.Germ cell tumor 10-year OS were 96%in the testis and 100%in the vagina.Interpretation:A better understanding of the overall distribution and outcomes associated with pediatric genitourinary cancers allows physicians to best understand the patient’s disease in the context of current frequency in a genitourinary setting and reported outcomes.展开更多
Atherosclerosis is a chronic inflammatory disease that is characterized by the build-up of lipid-rich plaques in the arterial walls. The standard treatment for patients with atherosclerosis is statin therapy aimed to ...Atherosclerosis is a chronic inflammatory disease that is characterized by the build-up of lipid-rich plaques in the arterial walls. The standard treatment for patients with atherosclerosis is statin therapy aimed to lower serum lipid levels. Despite its widespread use, many patients taking statins continue to experience acute events. Thus, to develop improved and alternative therapies, we previously reported on microRNA-145 (miR-145 micelles) and its ability to inhibit atherosclerosis by targeting vascular smooth muscle cells (VSMCs). Importantly, one dose of miR-145 micelles significantly abrogated disease progression when evaluated two weeks post-administration. Thus, in this study, to evaluate how long the sustained effects of miR-145 micelles can be maintained and towards identifying a dosing regimen that is practical for patients with chronic disease, the therapeutic effects of a single dose of miR-145 micelles were evaluated for up to two months in vivo. After one and two months post-treatment, miR-145 micelles were found to reduce plaque size and overall lesion area compared to all other controls including statins without causing adverse effects. Furthermore, a single dose of miR-145 micelle treatment inhibited VSMC transdifferentiation into pathogenic macrophage-like and osteogenic cells in plaques. Together, our data shows the long-term efficacy and sustained effects of miR-145 micelles that is amenable using a dosing frequency relevant to chronic disease patients.展开更多
文摘Rarely,scientific developments centered around the patient as a whole arepublished.Our multidisciplinary group,headed by gastrointestinal surgeons,applied this research philosophy considering the most important aspects of thediseases“colon-and rectal cancer”in the long-term developments.Good expertcooperation/knowledge at the Comprehensive Cancer Center Ulm(CCCU)wereapplied in several phase III trials for multimodal treatments of primary tumors(MMT)and metastatic diseases(involving nearly 2000 patients and 64 centers),fortreatment individualization of MMT and of metastatic disease,for psychooncology/quality of life involving the patients’wishes,and for disease prevention.Most of the targets initially were heavily rejected/discussed in thescientific communities,but now have become standards in treatments andnational guidelines or are topics in modern translational research protocolsinvolving molecular biology for e.g.,“patient centered individualized treatment”.In this context we also describe the paths we had to tread in order to realize ournew goals,which at the end were highly beneficial for the patients from manypoints of view.This description is also important for students and youngresearchers who,with an actual view on our recent developments,might want toknow how medical progress was achieved.
文摘Acute myeloid leukemia(AML)remains a biologically heterogeneous disease with historically limited targeted therapies and poor outcomes.The development of menin inhibitors represents a promising shift,particularly for patients harboring KMT2A rearrangements(KMT2Ar)and NPM1 mutations(NPM1m).This manuscript reviews the molecular rationale of menin inhibition for aberrant homeobox/myeloid ectopic insertion site 1(HOX/MEIS1)-driven gene expression and leukemogenesis,clinical trial outcomes,and safety data for menin inhibitors,with a focus on recently FDA-approved revumenib and several other agents in development,ziftomenib(KO-539),bleximenib(JNJ-75276617),and icovamenib(BMF-219).We also focused our discussion on future directions to include resistance mechanisms,biomarker identification and monitoring strategies,and combination therapies.Menin inhibition is now being clinically integrated into relapsed/refractory and frontline treatment settings.
文摘Nonhomologous DNA end joining （NHEJ） is the primary pathway for repair of double-strand DNA breaks in human cells and in multicellular eukaryotes. The causes of double-strand breaks often fragment the DNA at the site of damage, resulting in the loss of information there. NHEJ does not restore the lost information and may resect additional nucleotides during the repair process. The ability to repair a wide range of overhang and damage configurations reflects the flexibility of the nuclease, polymerases, and ligase of NHEJ. The flexibility of the individual components also explains the large number of ways in which NHEJ can repair any given pair of DNA ends. The loss of information locally at sites of NHEJ repair may contribute to cancer and aging, but the action by NHEJ ensures that entire segments of chromosomes are not lost.
文摘Currently the clinical management of breast cancer relies on relatively few prognostic/predictive clinical markers(estrogen receptor, progesterone receptor, HER2), based on primary tumor biology. Circulating biomarkers, such as circulating tumor DNA(ctDNA) or circulating tumor cells(CTCs) may enhance our treatment options by focusing on the very cells that are the direct precursors of distant metastatic disease, and probably inherently different than the primary tumor's biology. To shift the current clinical paradigm, assessing tumor biology in real time by molecularly profiling CTCs or ctDNA may serve to discover therapeutic targets, detect minimal residual disease and predict response to treatment. This review serves to elucidate the detection,characterization, and clinical application of CTCs and ctDNA with the goal of precision treatment of breast cancer.
文摘Bone metastases are the main driver of morbidity and mortality in advanced prostate cancer. Targeting the bone microenvironment, a key player in the pathogenesis of bone metastasis, has become one of the mainstays of therapy in men with advanced prostate cancer. This review will evaluate the data supporting the use of bone-targeted therapy, including （1） bisphosphonates such as zoledronic acid, which directly target osteoclasts, （2） denosumab, a receptor activator of nuclear factor-kappa B （RANK） ligand inhibitor, which targets a key component of bone stromal interaction, and （3） radium-223, an alpha-emitting calcium mimetic, which hones to the metabolically active areas of osteoblastic metastasis and induces double-strand breaks in the DNA. Denosumab has shown enhanced delay in skeletal-related events compared to zoledronic acid in patients with metastatic castration-resistant prostate cancer （mCRPC）. Data are mixed with regard to pain control as a primary measure of efficacy. New data call into question dosing frequency, with quarterly dosing strategy potentially achieving similar effect compared to monthly dosing for zoledronic acid. In the case of radium-223, there are data for both pain palliation and improved overall survival in mCRPC. Further studies are needed to optimize timing and combination strategies for bone-targeted therapies. Ongoing studies will explore the impact of combining bone-targeted therapy with investigational therapeutic agents such as immunotherapy, for advanced prostate cancer. Future studies should strive to develop biomarkers of response, in order to improve efficacy and cost-effectiveness of these agents.
文摘MicroRNAs(miRNAs)are small noncoding RNAs involved in the regulation of mRNA transcription and translation,and possess all desirable features of an ideal tumor marker.Of almost 31 different miRNA clusters identified in germ cell tumors(GCTs),miR-371a-3p has shown exceptionally high sensitivity and specificity for both seminomatous and nonseminomatous GCTs.It is easily obtainable and correlates well with tumor burden.Recent multiinstitutional prospective studies have shown promising test characteristics for miR-371a-3p as a diagnostic blood-based biomarker for GCT prior to orchiectomy including 80%e100%sensitivity and 90%e100%specificity.This accuracy may address other unmet needs in the management of patients with GCT.Early studies have suggested the utility of miR-371a-3p in detecting occult nodal metastasis in high-risk clinical stage I and early stage II disease.Ongoing clinical trials including SWOG 1823 and AGCT1531 are specifically designed to confirm the utility of miR-371a-3p in clinical stage I GCT.Despite its strong association with viable GCT after treatment with chemotherapy,miR-371a-3p does not seem to accurately predict the presence of teratoma in residual lesions.Also,standardization of extraction and interpretation methods is a necessary step to assure uniform results across different institutions.
文摘Objective:Radical nephroureterectomy(RNU)is considered the standard of care for patients with high-risk upper tract urothelial carcinoma.Current literature reveals a deficit in direct comparative studies evaluating the efficacy of different chemotherapeutic agents administered in single postoperative instillation following RNU.The primary aim of this study was to compare the bladder recurrence(BR)rates between patients receiving a single instillation of mitomycin C(MMC)versus gemcitabine(Gem)after RNU.Methods:The ROBUUST(ROBotic surgery for Upper tract Urothelial cancer STudy)2.0 is an international,multicenter registry that aggregates data on patients who have undergone curative surgery for upper tract urothelial carcinoma across participating centers from January 2015 to December 2022.Data including primary baseline variables of the patients,characteristics of the tumors,surgical management,and definitive histopathological characterizations were collected and stratified based on the type of postoperative bladder instillation:MMC(the MMC group)and Gem(the Gem group).We selected variables correlated with our primary outcome to conduct a propensity-score match analysis.Results:One hundred patients in the MMC group were matched 1:1 with 100 patients in the Gem group.At 36 months of follow-up,30 patients in the MMC group and 39 patients in the Gem group experienced BR,representing recurrence rates of 30%and 39%,respectively(p=0.2).The Cox proportional hazards model comparing BR between the groups revealed a hazard ratio of 1.58(95%confidence interval:0.98-2.55)with a non-statistically significant increased risk of BR in the Gem group compared with the MMC group(p=0.059).Conclusion:A single perioperative instillation of Gem or MMC seems to offer similar efficacy in reducing the risk of BR in patients undergoing RNU.Further research,ideally within the framework of prospective studies,is warranted to elucidate the optimal chemotherapeutic approach in this setting.
基金This research was partially supported by the US National Science Foundation(No.1762941)the US National Institutes ofHealth(Nos.5R21HL162405,U54CA233396,U54CA233444,and U54CA233465).
文摘Coronavirus disease 2019(COVID-19),caused by severe acute respiratory syndrome coronavirus 2,has spread globally and threatens public health.Advanced in vitro models that recapitulate the architecture and functioning of specific tissues and organs are in high demand for COVID-19-related pathology studies and drug screening.Since three-dimensional in vitro cultures,such as self-assembled and engineered organoid cultures,surpass conventional two-dimensional cultures and animal models with respect to increased cellular complexity,an environment more relevant to humans,and reduced cost,they are promising platforms for understanding viral pathogenesis and developing new therapeutics.This review highlights the recent advances in self-assembled and engineered organoid technologies that are used for COVID-19 studies.The challenges and future perspectives are also discussed.
基金supported by the Joint Funds of the National Natural Science Foundation of China (U1603126) (to Z. X.)
文摘IκB kinase ε(IKKε) is a non-canonical IκB kinase that is extensively studied in the context of innate immune response. Recently, significant progress has been made in understanding the role of IKKεin interferon(IFN) signaling. In addition to its roles in innate immunity, recent studies also demonstrate that IKKε is a key regulator of the adaptive immune response. Specifically, IKKεfunctions as a negative feedback kinase to curtail CD8 T cell response, implying that it can be a potential therapeutic target to boost antiviral and antitumor T cell immunity. In this review, we highlight the roles of IKKε in regulating IFN signaling and T cell immunity, and discuss a few imminent questions that remain to be answered.
基金supported by the USC Graduate School Provost Fellowship,USC Viterbi School of Engineering,a National Institutes of Health(NIH)grant R01CA220012,and a STOP CANCER Marni Levine Memorial Research Career Development Awardsupported by shared resources from an NIH National Cancer Institute Award(P30CA014089).
文摘Cancer metabolism plays an essential role in therapeutic resistance,where significant inter-and intra-tumoral heterogeneity exists.Hypoxia is a prominent driver of metabolic rewiring behaviors and drug responses.Reca-pitulating the hypoxic landscape in the tumor microenvironment thus offers unique insights into heterogeneity in metabolic rewiring and therapeutic responses,to inform better treatment strategies.There remains a lack of scalable tools that can readily interface with imaging platforms and resolve the heterogeneous behaviors in hypoxia-associated metabolic rewiring.Here we present a micro-metabolic rewiring(μMeRe)assay that provides the scalability and resolution needed to characterize the metabolic rewiring behaviors of different cancer cells in the context of hypoxic solid tumors.Our assay generates hypoxia through cellular metabolism without external gas controls,enabling the characterization of cell-specific intrinsic ability to drive hypoxia and undergo meta-bolic rewiring.We further developed quantitative metrics that measure the metabolic plasticity through phe-notypes and gene expression.As a proof-of-concept,we evaluated the efficacy of a metabolism-targeting strategy in mitigating hypoxia-and metabolic rewiring-induced chemotherapeutic resistance.Our study and the scalable platform thus lay the foundation for designing more effective cancer treatments tailored toward specific meta-bolic rewiring behaviors.
基金The authors would like to acknowledge the financial support from the National Heart,Lung,and Blood Institute(NHLBI,R00HL124279)NIH New Innovator Award(DP2DK121328)L.K.Whittier Foundation,Ming Hsieh Institute for Research on Engineering-Medicine for Cancer,the Women in Science and Engineering Gabilan Assistant Professorship,and the University of Southern California startup funds awarded to EJC.
文摘Cancer progression is marked by the infiltration of immunosuppressive cells,such as tumor-associated macrophages(TAMs),regulatory T lymphocytes(Tregs),and myeloid-derived suppressor cells(MDSCs).These cells play a key role in abrogating the cytotoxic T lymphocyte-mediated(CTL)immune response,allowing tumor growth to proceed unabated.Furthermore,targeting these immunosuppressive cells through the use of peptides and peptide-based nanomedicine has shown promising results.Here we review the origins and functions of immunosuppressive cells in cancer progression,peptide-based systems used in their targeting,and explore future avenues of research regarding cancer immunotherapy.The success of these studies demonstrates the importance of the tumor immune microenvironment in the propagation of cancer and the potential of peptide-based nanomaterials as immunomodulatory agents.
文摘Anaplastic lymphoma kinase(ALK)gene rearrangements have been identified as potent oncogenic drivers in several malignancies,including non-small cell lung cancer(NSCLC).The discovery of ALK inhibition using a tyrosine kinase inhibitor(TKI)has dramatically improved the outcomes of patients with ALK-mutated NSCLC.However,the emergence of intrinsic and acquired resistance inevitably occurs with ALK TKI use.This review describes the molecular mechanisms of ALK TKI resistance and discusses management strategies to overcome therapeutic resistance.
文摘The treatment scenario of colorectal cancer(CRC)has been evolving in recent years with the introduction of novel targeted agents and new therapeutic strategies for the metastatic disease.An extensive effort has been directed to the identification of predictive biomarkers to aid patients selection and guide therapeutic choices.Pharmacogenomics represents an irreplaceable tool to individualize patients treatment based on germline and tumor acquired somatic genetic variations able to predict drugs response and risk of toxicities.The growing knowledge of CRC molecular characteristics and complex genomic makeup has played a crucial role in identifying predictive pharmacogenomic biomarkers,while supporting the rationale for the development of new drugs and treatment combinations.Clinical validation of promising biomarkers,however,is often an issue.More recently,a deeper understanding of resistance mechanisms and tumor escape dynamics under treatment pressure and the availability of novel technologies are opening new perspectives in this field.This review aims to present an overview of current pharmacogenomic biomarkers and future perspectives of pharmacogenomics in CRC,in an evolving scenario moving from a single drug-gene interactions approach to a more comprehensive genome-wide approach,comprising genomics and epigenetics.
基金NIH,Grant/Award Number:R03 AG070669Canadian Institutes of Health Research,European Commission’s Seventh Framework Programme grant agreement,Grant/Award Number:HEALTH-F2-2009-223175+11 种基金Cancer Research UK,Grant/Award Numbers:C5047/A7357,C1287/A10118,C1287/A16563,C5047/A3354,C5047/A10692,C16913/A6135The National Institute of Health(NIH)Cancer Post-Cancer GWAS,Grant/Award Number:1 U19 CA 148537-01The National Health and Medical Research Council,Australia,Grant/Award Numbers:126402,209057,251533,396414,450104,504700,504702,504715,623204,940394,614296US National Institutes of Health(NIH),Grant/Award Number:U19 CA 148537Prostate cancer SuscEptibility(ELLIPSE),Grant/Award Number:X01HG007492Center for Inherited Disease Research(CIDR),Grant/Award Number:HHSN268201200008INIH NCI,Grant/Award Number:U01 CA188392European Community’s Seventh Framework Programme,Grant/Award Number:223175Post-Cancer GWAS initiative,Grant/Award Numbers:1U19 CA148537,1U19 CA148065,1U19 CA148112U.S.National Institutes of Health,National Cancer Institute,Grant/Award Numbers:U01-CA98233,U01-CA98710,U01-CA98216,U01-CA98758Swedish Cancer Foundation,Grant/Award Numbers:09-0677,11-484,12-823Swedish Research Council,Swedish Research Council,Grant/Award Numbers:K2010-70X-20430-04-3,2014-2269。
文摘Background:DNA methylation and gene expression are known to play important roles in the etiology of human diseases such as prostate cancer(PCa).However,it has not yet been possible to incorporate information of DNA methylation and gene expression into polygenic risk scores(PRSs).Here,we aimed to develop and validate an improved PRS for PCa risk by incorporating genetically predicted gene expression and DNA methylation,and other genomic information using an integrative method.Methods:Using data from the PRACTICAL consortium,we derived multiple sets of genetic scores,including those based on available single-nucleotide polymorphisms through widely used methods of pruning and thresholding,LDpred,LDpred-funt,AnnoPred,and EBPRS,as well as PRS constructed using the genetically predicted gene expression and DNA methylation through a revised pruning and thresholding strategy.In the tuning step,using the UK Biobank data(1458 prevalent cases and 1467 controls),we selected PRSs with the best performance.Using an independent set of data from the UK Biobank,we developed an integrative PRS combining information from individual scores.Furthermore,in the testing step,we tested the performance of the integrative PRS in another independent set of UK Biobank data of incident cases and controls.Results:Our constructed PRS had improved performance(C statistics:76.1%)over PRSs constructed by individual benchmark methods(from 69.6%to 74.7%).Furthermore,our new PRS had much higher risk assessment power than family history.The overall net reclassification improvement was 69.0%by adding PRS to the baseline model compared with 12.5%by adding family history.Conclusions:We developed and validated a new PRS which may improve the utility in predicting the risk of developing PCa.Our innovative method can also be applied to other human diseases to improve risk prediction across multiple outcomes.
文摘One in three Americans is at risk for developing chronic kidney disease （CKD） and end-stage renal disease （ESRD）, leading to the need for dialysis or a kidney transplant. Small-molecule drugs have been proposed as therapies to manage kidney diseases, but high dosages are often required to achieve therapeutic efficacy, generating off-target side effects, some of which are lethal. To address these limitations, we developed a novel kidney-targeting multimodal micelle （KM） system for drug delivery applications. SpecificaU~ we incorporated the kidney-targeting peptide （Lysine-Lysine-Glutamic acid-Glutamic acid-Glutamic acid）3-Lysine） （（KKEEE）3K） into micelles. This peptide binds to megalin, a multi-ligand cell surface receptor present on renal tubule cells. When incubated with human kidney proximal tubule cells, KMs were found to be biocompatible in vitro. In vivo, KMs showed higher accumulation in the kidneys as compared to a non-targeted （NT） control upon intravenous injection in wild-type C57BL/6J mice. Histological evaluation showed no signs of tissue damage, while blood urea nitrogen （BUN） and creatinine levels were within normal ranges, validating the preservation of kidney health upon micelle administration. To our knowledge, this is the first utilization of （KKEEE）BK in a nanoparticle formulation, and our study offers strong evidence that this novel nanoparticle platform can be used as a candidate drug delivery carrier to direct therapeutics to diseased tissue in CKD.
基金The author’s laboratory is currently supported by NIH grants(R01CA167181R01GM089684 and R21CA192003)the University of Southern California Norris Comprehensive Cancer Center
文摘On October 7, 2015, the Nobel Prize Committee announced that the 2015 Nobel Prize in Chemistry had been awarded jointly to Professors Paul Modrich, Tomas Lindahl and Aziz Sancar （Figure 1）, each of whom made ground-breaking discoveries about the molecular mechanisms of DNA Re- pair. In one of life＇s unpredictable turns, Paul was among the last individuals in his entire personal, professional and social network to learn of the Committee＇s decision, be- cause Paul was very far ＂off-the-grid＂ at the time of the announcement. The news that he had been selected as a 2015 Nobel Laureate may have taken Paul by surprise, but it certainly was not a surprise to most, if not all, of Paul＇s colleagues, students, family and friends.
基金The project described was supported by the DHHS grant R43CA177067(Uckun FM)from the National Cancer Institute.The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Cancer Institute or the National Institutes of Health.Uckun FM was also supported in part by DHHS grants P30CA014089,U01-CA-151837,R01CA-154471 and R21-CA-164098(Uckun FM)from the National Cancer Instituteby the V-Foundation,Nautica Triathlon as well as the Ronald McDonald House Charities of Southern California.
文摘Aim:CD22ΔE12 as an oncogenic driver lesion in aggressive and drug-resistant B-precursor acute lymphoblastic leukemia(BPL)cells.The purpose of the present study was to identify the CD22ΔE12-specific signature transcriptome in human BPL cells and evaluate the clinical potential of a nanoscale formulation of CD22ΔE12-siRNA as an RNAi therapeutic against drug-resistant BPL.CD22ΔE12-siRNA nanoparticles significantly improved the event-free survival(EFS)outcome of NOD/SCID(NS)mice challenged with human BPL xenograft cells.Methods:Gene expression and translational bioinformatics methods were applied to examine the expression of the CD22ΔE12-specific signature transcriptome in human BPL cells in subsets of BPL patients.Survival analysis for mice challenged with BPL cells and treated with CD22ΔE12 siRNA was performed using standard methods.Results:Leukemia cells from CD22ΔE12-Tg mice exhibit gene and protein expression profiles consistent with constitutive activation of multiple signaling networks,mimicking the profiles of relapsed BPL patients as well as newly diagnosed high-risk patients with BCR-ABL+/Philadelphia chromosome(Ph)+BPL as well as Ph-like BPL.A nanoscale formulation of CD22ΔE12-siRNA abrogated the in vivo clonogenicity of the leukemia-initiating leukemic cell fraction in xenograft specimens derived from patients with relapsed BPL and significantly improved the EFS outcome of NS mice challenged with drug-resistant human BPL xenograft cells.Conclusion:The CD22-RNAi technology is applicable to all BPL patients both high risk and standard risk.That is because CD22ΔE12 is a characteristic feature of drug-resistant leukemic clones that escape chemotherapy and cause relapse in both high risk and low risk subgroups of patients.The technology therefore has the potential(1)for prevention of relapses by selectively killing the clones that are most likely to escape chemotherapy and cause relapse as well(2)for treatment of relapses in BPL.This research project may also lead to innovative salvage regimens against other forms of CD22ΔE12-positive relapsed B-lineage leukemias and lymphomas.
基金supported by the National Institutes of Health (CA167181, CA192003, GM112702)the Cancer Prevention and Research Institute of Texas (CPRIT)
文摘Trinucleotide repeat expansions cause over 30 severe neuromuscular and neurodegenerative disorders, including Huntington's disease, myotonic dystrophy type 1, and fragile X syndrome. Although previous studies have substantially advanced the understanding of the disease biology, many key features remain unknown. DNA mismatch repair(MMR) plays a critical role in genome maintenance by removing DNA mismatches generated during DNA replication. However, MMR components,particularly mismatch recognition protein MutSβ and its interacting factors MutLα and MutLγ, have been implicated in trinucleotide repeat instability. In this review, we will discuss the roles of these key MMR proteins in promoting trinucleotide repeat instability.
文摘Importance:The diversity of pediatric genitourinary malignancies requires a timely resource detailing tumor characteristics and survival.Objective:To determine the incidence,demographics,and outcomes of all pediatric genitourinary tumors within the United States.Methods:A population-based search for patients diagnosed with genitourinary cancers under age 15 was performed using the National Cancer Institute’s Surveillance,Epidemiology,and End Results 18 registry.Information on primary tumor location,histologic type,patient age,sex,year of diagnosis,race,treatment,cause of death,and survival months was extracted.Descriptive epidemiological and survival statistics were calculated for all variables.Results:A total of 4576 cases from 1973 through 2015 were identified.The most common primary tumor sites were the kidney(80.3%),testis(12.3%),bladder(2.8%),and vagina(1.5%).Nephroblastoma(87.9%)and sarcoma(3.4%)were the most common renal malignancies.Rhabdomyosarcoma was common in the vagina,bladder,and testis at rates of 66.2%,61.2%,and 24.6%,respectively.Germ cell tumors(71.0%)were the most common primary tumor of the testis.Ten-year overall survival(OS)for renal nephroblastoma and sarcoma was 88%and 82%,respectively.Ten-year OS for RMS of the testis was 91%,the bladder was 79%,the vagina was 79%,and the prostate was 56%.Germ cell tumor 10-year OS were 96%in the testis and 100%in the vagina.Interpretation:A better understanding of the overall distribution and outcomes associated with pediatric genitourinary cancers allows physicians to best understand the patient’s disease in the context of current frequency in a genitourinary setting and reported outcomes.
基金support by the University of Southern California,the NSF Graduate Research Fellowship Program awarded to N.P.,and the American Heart Association Transformational Project Award(968730)the National Heart,Lung,and Blood Institute(R00HL124279)New Innovator Award(DP2-DK121328)granted to E.J.C.We would also like to thank Dr.Gary Owens for his generosity in providing the SMClin mice used for these studies.
文摘Atherosclerosis is a chronic inflammatory disease that is characterized by the build-up of lipid-rich plaques in the arterial walls. The standard treatment for patients with atherosclerosis is statin therapy aimed to lower serum lipid levels. Despite its widespread use, many patients taking statins continue to experience acute events. Thus, to develop improved and alternative therapies, we previously reported on microRNA-145 (miR-145 micelles) and its ability to inhibit atherosclerosis by targeting vascular smooth muscle cells (VSMCs). Importantly, one dose of miR-145 micelles significantly abrogated disease progression when evaluated two weeks post-administration. Thus, in this study, to evaluate how long the sustained effects of miR-145 micelles can be maintained and towards identifying a dosing regimen that is practical for patients with chronic disease, the therapeutic effects of a single dose of miR-145 micelles were evaluated for up to two months in vivo. After one and two months post-treatment, miR-145 micelles were found to reduce plaque size and overall lesion area compared to all other controls including statins without causing adverse effects. Furthermore, a single dose of miR-145 micelle treatment inhibited VSMC transdifferentiation into pathogenic macrophage-like and osteogenic cells in plaques. Together, our data shows the long-term efficacy and sustained effects of miR-145 micelles that is amenable using a dosing frequency relevant to chronic disease patients.
