Digital Commons Network^™

Efficacy Of Laser Interstitial Thermal Therapy (Litt) For Newly Diagnosed And Recurrent Idh Wild-Type Glioblastoma, John F De Groot, Albert H Kim, Et Al.

2020-Current year OA Pubs

BACKGROUND: Treatment options for unresectable new and recurrent glioblastoma remain limited. Laser ablation has demonstrated safety as a surgical approach to treating primary brain tumors. The LAANTERN prospective multicenter registry (NCT02392078) data were analyzed to determine clinical outcomes for patients with new and recurrent

METHODS: Demographics, intraprocedural data, adverse events, KPS, health economics, and survival data were prospectively collected and then analyzed on

RESULTS: A total of 29 new and 60 recurrent

CONCLUSIONS: Laser ablation is a viable option for patients with new and recurrent glioblastoma. Median OS for

Combination Laser Interstitial Thermal Therapy Plus Stereotactic Radiotherapy Increases Time To Progression For Biopsy-Proven Recurrent Brain Metastases, Matthew M Grabowski, Alex Scott, Michael Olufawo, Albert H Kim, Eric C Leuthardt, Et Al.

2020-Current year OA Pubs

BACKGROUND: Improved survival for patients with brain metastases has been accompanied by a rise in tumor recurrence after stereotactic radiotherapy (SRT). Laser interstitial thermal therapy (LITT) has emerged as an effective treatment for SRT failures as an alternative to open resection or repeat SRT. We aimed to evaluate the efficacy of LITT followed by SRT (LITT+SRT) in recurrent brain metastases.

METHODS: A multicenter, retrospective study was performed of patients who underwent treatment for biopsy-proven brain metastasis recurrence after SRT at an academic medical center. Patients were stratified by "planned LITT+SRT" versus "LITT alone" versus "repeat SRT alone." Index lesion progression …

Case Report: "Primary Immunodeficiency"-Severe Autoimmune Enteropathy In A Pediatric Heart Transplant Recipient Treated With Abatacept And Alemtuzumab, Elizaveta Kalaidina, Elizabeth C Utterson, Deepa Mokshagundam, Mai He, Shalini Shenoy, Megan A Cooper

2020-Current year OA Pubs

Disorders of immune dysregulation following heart transplantation in children have been reported; however, the management of such disorders remains uncertain and challenging. In this case report, we describe a clinical course of a child with severe autoimmune enteropathy after a heart transplant in infancy and detail a treatment approach with abatacept and alemtuzumab. A 21-month-old girl with a medical history of congenital dilated cardiomyopathy and heart transplantation at 2 months was evaluated for chronic hematochezia. The patient underwent an extensive workup, including endoscopic biopsy which showed crypt apoptosis, similar to that seen with graft-versus-host disease (GVHD). Results of her immune …

Prospective Biomarker Study In Newly Diagnosed Glioblastoma: Cyto-C Clinical Trial, Corinne E Griguer, Milan G Chheda, Et Al.

2020-Current year OA Pubs

BACKGROUND: Glioblastoma (GBM) has a 5-year survival rate of 3%-5%. GBM treatment includes maximal resection followed by radiotherapy with concomitant and adjuvant temozolomide (TMZ). Cytochrome C oxidase (CcO) is a mitochondrial enzyme involved in the mechanism of resistance to TMZ. In a prior retrospective trial, CcO activity in GBMs inversely correlated with clinical outcome. The current Cyto-C study was designed to prospectively evaluate and validate the prognostic value of tumor CcO activity in patients with newly diagnosed primary GBM, and compared to the known prognostic value of

METHODS: This multi-institutional, blinded, prospective biomarker study enrolled 152 patients with newly diagnosed …

Association Between Recent Overdose And Chronic Pain Among Individuals In Treatment For Opioid Use Disorder, Sarah M. Hartz, Robert C. Culverhouse, Carrie M. Mintz, Matthew S. Ellis, Zachary A. Kasper, Patricia Cavazos-Rehg, Richard A. Grucza, Laura J. Bierut, Theodore J. Cicero

2020-Current year OA Pubs

Chronic pain increases risk for opioid overdose among individuals with opioid use disorder. The purpose of this study is to evaluate the relationship between recent overdose and whether or not chronic pain is active. 3,577 individuals in treatment for opioid use disorder in 2017 or 2018 were surveyed regarding recent overdoses and chronic pain. Demographics from the 2017 Treatment Episode Data Set, which includes all U.S. facilities licensed or certified to provide substance use care, were used to evaluate the generalizability of the sample. χ2 tests and logistic regression models were used to compare associations between recent overdoses and chronic …

Barriers And Facilitators To Diabetes Screening And Prevention After A Pregnancy Complicated By Gestational Diabetes, Drishti D. Sinha, Roxann C. Williams, Laura N. Hollar, Hannah R. Lucas, Bethany Johnson-Javois, Heidi B. Miller, Amanda Stoermer, Graham A. Colditz, Aimee S. James, Cynthia J. Herrick

2020-Current year OA Pubs

OBJECTIVE: Gestational diabetes mellitus (GDM) is increasing in the United States, with higher rates among minoritized racial and ethnic populations and lower income populations. GDM increases risk for type 2 diabetes (T2DM), and postpartum diabetes screening and prevention are imperative. This qualitative study examines barriers and facilitators to postpartum T2DM screening and prevention among non-privately insured individuals with a history of GDM in a state prior to Medicaid expansion.

METHODS: Thirty-six non-privately insured women with a history of GDM completed semi-structured interviews. Four focus groups and seven interviews were conducted with 30 nurse practitioners, physicians, physician assistants, nurses and registered …

Mitochondrial Fitness And Cancer Risk, Andrew V. Kossenkov, Andrew Milcarek, Faiyaz Notta, Gun-Ho Jang, Julie M. Wilson, Steven Gallinger, Daniel Cui Zhou, Li Ding, Jagadish C. Ghosh, Michela Perego, Annamaria Morotti, Marco Locatelli, Marie E. Robert, Valentina Vaira, Dario C. Altieri

2020-Current year OA Pubs

Changes in metabolism are a hallmark of cancer, but molecular signatures of altered bioenergetics to aid in clinical decision-making do not currently exist. We recently identified a group of human tumors with constitutively reduced expression of the mitochondrial structural protein, Mic60, also called mitofilin or inner membrane mitochondrial protein (IMMT). These Mic60-low tumors exhibit severe loss of mitochondrial fitness, paradoxically accompanied by increased metastatic propensity and upregulation of a unique transcriptome of Interferon (IFN) signaling and Senescence-Associated Secretory Phenotype (SASP). Here, we show that an optimized, 11-gene signature of Mic60-low tumors is differentially expressed in multiple malignancies, compared to normal …

In And Out: Leishmania Metastasis By Hijacking Lymphatic System And Migrating Immune Cells, Baijayanti Jha, Marta Reverte, Catherine Ronet, Florence Prevel, Florence D Morgenthaler, Chantal Desponds, Lon-Fye Lye, Katherine L Owens, Leonardo Scarpellino, Lalit Kumar Dubey, Amélie Sabine, Tatiana V Petrova, Sanjiv A Luther, Stephen M Beverley, Nicolas Fasel

2020-Current year OA Pubs

The lymphatic system plays a crucial role in mounting immune response against intracellular pathogens, and recent studies have documented its role in facilitating tumor dissemination linked largely with cancer cells. However, in mucocutaneous leishmaniasis (MCL) caused by

Four Decades Of Mapping And Quantifying Neuroreceptors At Work In Vivo By Positron Emission Tomography, Albert Gjedde, Dean F Wong

2020-Current year OA Pubs

Decryption of brain images is the basis for the necessary translation of the findings from imaging to information required to meet the demands of clinical intervention. Tools of brain imaging, therefore, must satisfy the conditions dictated by the needs for interpretation in terms of diagnosis and prognosis. In addition, the applications must serve as fundamental research tools that enable the understanding of new therapeutic drugs, including compounds as diverse as antipsychotics, antidepressants, anxiolytics, and drugs serving the relief of symptoms from neurochemical disorders as unrelated as multiple sclerosis, stroke, and dementia. Here we review and explain the kinetics of methods …

Enhancing Neuroimaging Genetics Through Meta-Analysis For Tourette Syndrome (Enigma-Ts): A Worldwide Platform For Collaboration, Peristera Paschou, Emily D Bihun, Tamara Hershey, Jonathan M Koller, Kevin J. Black, Et Al.

2020-Current year OA Pubs

Tourette syndrome (TS) is characterized by multiple motor and vocal tics, and high-comorbidity rates with other neuropsychiatric disorders. Obsessive compulsive disorder (OCD), attention deficit hyperactivity disorder (ADHD), autism spectrum disorders (ASDs), major depressive disorder (MDD), and anxiety disorders (AXDs) are among the most prevalent TS comorbidities. To date, studies on TS brain structure and function have been limited in size with efforts mostly fragmented. This leads to low-statistical power, discordant results due to differences in approaches, and hinders the ability to stratify patients according to clinical parameters and investigate comorbidity patterns. Here, we present the scientific premise, perspectives, and key …

Cd4+ T-Lymphocytes Exhibit Biphasic Kinetics Post-Myocardial Infarction, Vinay Kumar, Sumanth D Prabhu, Shyam S Bansal

2020-Current year OA Pubs

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Combination Tigit/Pd-1 Blockade Enhances The Efficacy Of Neoantigen Vaccines In A Model Of Pancreatic Cancer, Hui Peng, Lijin Li, Chong Zuo, Michael Y Chen, Xiuli Zhang, Nancy B Myers, Graham D Hogg, David G Denardo, S Peter Goedegebuure, William G Hawkins, William E Gillanders

2020-Current year OA Pubs

BACKGROUND: Cancer neoantigens are important targets of cancer immunotherapy and neoantigen vaccines are currently in development in pancreatic ductal adenocarcinoma (PDAC) and other cancer types. Immune regulatory mechanisms in pancreatic cancer may limit the efficacy of neoantigen vaccines. Targeting immune checkpoint signaling pathways in PDAC may improve the efficacy of neoantigen vaccines.

METHODS: We used KPC4580P, an established model of PDAC, to test whether neoantigen vaccines can generate therapeutic efficacy against PDAC. We focused on two immunogenic neoantigens associated with genetic alterations in the CAR12 and CDK12 genes. We tested a neoantigen vaccine comprised of two 20-mer synthetic long peptides …

Mechanisms Of Persistent Atrial Fibrillation And Recurrences Within 12 Months Post-Ablation: Non-Invasive Mapping With Electrocardiographic Imaging, Ramya Vijayakumar, Mitchell N Faddis, Phillip S Cuculich, Yoram Rudy

2020-Current year OA Pubs

INTRODUCTION: Catheter ablation of persistent AF has not been consistently successful in terminating AF or preventing arrhythmia recurrences. Non-invasive Electrocardiographic Imaging (ECGI) can help to understand recurrences by mapping the mechanisms of pre-ablation AF and comparing them with the patterns of recurrent arrhythmias in the same patient.

METHODS: Seventeen persistent AF patients underwent ECGI before their first catheter ablation. Time-domain activation maps and phase progression maps were obtained on the bi-atrial epicardium. Location of arrhythmogenic drivers were annotated on the bi-atrial anatomy. Activation and phase movies were examined to understand the wavefront dynamics during AF. Eight patients recurred within 12 …

Islet Cilia And Glucose Homeostasis, Isabella Melena, Jing W Hughes

2020-Current year OA Pubs

Diabetes is a growing pandemic affecting over ten percent of the U.S. population. Individuals with all types of diabetes exhibit glucose dysregulation due to altered function and coordination of pancreatic islets. Within the critical intercellular space in pancreatic islets, the primary cilium emerges as an important physical structure mediating cell-cell crosstalk and signal transduction. Many events leading to hormone secretion, including GPCR and second-messenger signaling, are spatiotemporally regulated at the level of the cilium. In this review, we summarize current knowledge of cilia action in islet hormone regulation and glucose homeostasis, focusing on newly implicated ciliary pathways that regulate insulin …

The Relevance Of Rich Club Regions For Functional Outcome Post-Stroke Is Enhanced In Women, Anna K. Bonkhoff, Laura Heitsch, Chia-Ling Phuah, Et Al.

2020-Current year OA Pubs

No abstract provided.

Evaluation Of Dose-Dependent Treatment Effects After Mid-Trial Dose Escalation In Biomarker, Clinical, And Cognitive Outcomes For Gantenerumab Or Solanezumab In Dominantly Inherited Alzheimer's Disease, Guoqiao Wang, Yan Li, Chengjie Xiong, Eric Mcdade, David B Clifford, Susan L Mills, Anna M Santacruz, Andrew J Aschenbrenner, Jason Hassenstab, Tammie L S Benzinger, Brian A Gordon, Anne M Fagan, Kelley A Coalier, Jorge J Libre-Guerra, Austin Mccullough, Nelly Joseph-Mathurin, Charles D Chen, Randall J Bateman, Et Al.

2020-Current year OA Pubs

INTRODUCTION: While the Dominantly Inherited Alzheimer Network Trials Unit (DIAN-TU) was ongoing, external data suggested higher doses were needed to achieve targeted effects; therefore, doses of gantenerumab were increased 5-fold, and solanezumab was increased 4-fold. We evaluated to what extent mid-trial dose increases produced a dose-dependent treatment effect.

METHODS: Using generalized linear mixed effects (LME) models, we estimated the annual low- and high-dose treatment effects in clinical, cognitive, and biomarker outcomes.

RESULTS: Both gantenerumab and solanezumab demonstrated dose-dependent treatment effects (significant for gantenerumab, non-significant for solanezumab) in their respective target amyloid biomarkers (Pittsburgh compound B positron emission tomography standardized uptake …

Donor Chimerism And Immune Reconstitution Following Haploidentical Transplantation In Sickle Cell Disease, Yaya Chu, Brenda Grossman, Shalini Shenoy, Et Al

2020-Current year OA Pubs

INTRODUCTION: We previously reported the initial results of a phase II multicenter transplant trial using haploidentical parental donors for children and aolescents with high-risk sickle cell disease achieving excellent survival with exceptionally low rates of graft-versus-host disease and resolution of sickle cell disease symptoms. To investigate human leukocyte antigen (HLA) sensitization, graft characteristics, donor chimerism, and immune reconstitution in these recipients.

METHODS: CD34 cells were enriched using the CliniMACS

RESULTS: HLA antibodies were detected in 7 of 11 (64%) evaluable patients but rarely were against donor antigens. Myeloid engraftment was rapid (100%) at a median of 9 days. At 30 …

Primates Chunk Simultaneously-Presented Memoranda, Charles D Holmes, Shinung Ching, Lawrence H Snyder

2020-Current year OA Pubs

Though much research has characterized both the behavior and electrophysiology of spatial memory for single targets in non-human primates, we know much less about how multiple memoranda are handled. Multiple memoranda may interact in the brain, affecting the underlying representations. Mnemonic resources are famously limited, so items may compete for "space" in memory or may be encoded cooperatively or in a combined fashion. Understanding the mode of interaction will inform future neural studies. As a first step, we quantified interactions during a multi-item spatial memory task. Two monkeys were shown 1-4 target locations. After a delay, the targets reappeared with …

Characterization Of The Genomic And Immunologic Diversity Of Malignant Brain Tumors Through Multisector Analysis, Maximilian O Schaettler, Megan M Richters, Anthony Z Wang, Zachary L Skidmore, Bryan Fisk, Albert H Kim, Michael R Chicoine, Joshua W Osbun, Eric C Leuthardt, Joshua L Dowling, Gregory J Zipfel, Ralph G Dacey, Hsiang-Chih Lu, Tanner M Johanns, Obi L Griffith, Malachi Griffith, Gavin P Dunn, Et Al.

2020-Current year OA Pubs

Despite some success in secondary brain metastases, targeted or immune-based therapies have shown limited efficacy against primary brain malignancies such as glioblastoma (GBM). Although the intratumoral heterogeneity of GBM is implicated in treatment resistance, it remains unclear whether this diversity is observed within brain metastases and to what extent cancer cell-intrinsic heterogeneity sculpts the local immune microenvironment. Here, we profiled the immunogenomic state of 93 spatially distinct regions from 30 malignant brain tumors through whole-exome, RNA, and T-cell receptor sequencing. Our analyses identified differences between primary and secondary malignancies, with gliomas displaying more spatial heterogeneity at the genomic and neoantigen …

Genetic And Transcriptional Contributions To Relapse In Normal Karyotype Acute Myeloid Leukemia, Allegra A Petti, Saad M Khan, Ziheng Xu, Nichole Helton, Catrina C Fronick, Robert Fulton, Sai M Ramakrishnan, Sridhar Nonavinkere Srivatsan, Sharon E Heath, Peter Westervelt, Jacqueline E Payton, Matthew J Walter, Daniel C Link, John Dipersio, Christopher Miller, Timothy J Ley

2020-Current year OA Pubs

To better understand clonal and transcriptional adaptations after relapse in patients with acute myeloid leukemia (AML), we collected presentation and relapse samples from six normal karyotype AML cases. We performed enhanced whole-genome sequencing to characterize clonal evolution, and deep-coverage single-cell RNA sequencing on the same samples, which yielded 142,642 high-quality cells for analysis. Identifying expressed mutations in individual cells enabled us to discriminate between normal and AML cells, to identify coordinated changes in the genome and transcriptome, and to identify subclone-specific cell states. We quantified the coevolution of genetic and transcriptional heterogeneity during AML progression, and found that transcriptional changes …

Reciprocal Regulation Of Mitofusin 2-Mediated Mitophagy And Mitochondrial Fusion By Different Pink1 Phosphorylation Events, Jiajia Li, Xiawei Dang, Antonietta Franco, Gerald W Dorn

2020-Current year OA Pubs

Mitochondrial repair is essential to metabolic homeostasis. Outer mitochondrial membrane mitofusin (MFN) proteins orchestrate mitochondrial fusion that opposes mitochondrial degeneration caused by senescence. Depending upon physiological context, MFN2 can either mediate mitochondrial fusion or recruit cytosolic Parkin to initiate mitophagic elimination. Because it is not clear how these events are counter-regulated we engineered and expressed MFN2 mutants that mimic phosphorylated or non-phosphorylatable MFN2 at its PINK1 phosphorylation sites: T111, S378, and S442. By interrogating mitochondrial fusion, polarization status, and Parkin binding/mitophagy as a function of inferred MFN2 phosphorylation, we discovered that individual MFN2 phosphorylation events act as a biological "bar-code", …

Bridging The Technological Divide: Stigmas And Challenges With Technology In Digital Brain Health Studies Of Older Adults, Jessica Nicosia, Andrew J Aschenbrenner, Sarah L Adams, Marisol Tahan, Sarah H Stout, Hannah Wilks, Joyce E Balls-Berry, John C Morris, Jason Hassenstab

2020-Current year OA Pubs

The COVID-19 pandemic has increased adoption of remote assessments in clinical research. However, longstanding stereotypes persist regarding older adults' technology familiarity and their willingness to participate in technology-enabled remote studies. We examined the validity of these stereotypes using a novel technology familiarity assessment (

Intraocular Human Cytomegaloviruses Of Ocular Diseases Are Distinct From Those Of Viremia And Are Capable Of Escaping From Innate And Adaptive Immunity By Exploiting Hla-E-Mediated Peripheral And Central Tolerance, Mariko Shirane, Michael Paley, Wayne M Yokoyama, Et Al.

2020-Current year OA Pubs

Human cytomegalovirus (HCMV) infections develop into CMV diseases that result in various forms of manifestations in local organs. CMV-retinitis is a form of CMV disease that develops in immunocompromised hosts with CMV-viremia after viruses in the peripheral circulation have entered the eye. In the HCMV genome, extensive diversification of the UL40 gene has produced peptide sequences that modulate NK cell effector functions when loaded onto HLA-E and are subsequently recognized by the NKG2A and NKG2C receptors. Notably, some HCMV strains carry UL40 genes that encode peptide sequences identical to the signal peptide sequences of specific HLA-A and HLA-C allotypes, which …

Yoga Therapy During Chemotherapy For Early-Stage And Locally Advanced Breast Cancer, Samantha K Greaney, Neha Amin, Bethany C Prudner, Maggie Compernolle, Linda J Sandell, Susan C Tebb, Katherine N Weilbaecher, Peri Abeln, Jingqin Luo, Yu Tao, Angela C Hirbe, Lindsay L Peterson

2020-Current year OA Pubs

BACKGROUND: Chemotherapy is associated with decreased quality of life (QOL), fatigue, depression, and weight gain in patients with breast cancer. Weight gain is associated with poorer prognosis. Yoga improves QOL, fatigue, and mood in women with breast cancer but its effect on treatment-related weight gain has not been studied. The aim of this trial was to determine the feasibility of personalized yoga therapy in women receiving treatment for early-stage or locally advanced breast cancer and assess its impact on weight gain.

METHODS: Thirty women were randomized 1:1 to receive yoga therapy by a certified yoga therapist during treatment or a …

The Enantiomer Of Allopregnanolone Prevents Pressure-Mediated Retinal Degeneration Via Autophagy, Makoto Ishikawa, Toru Nakazawa, Hiroshi Kunikata, Kota Sato, Takeshi Yoshitomi, Kathiresan Krishnan, Douglas F Covey, Charles F Zorumski, Yukitoshi Izumi

2020-Current year OA Pubs

In an

Protocol For The Perioperative Outcome Risk Assessment With Computer Learning Enhancement (Periop Oracle) Randomized Study, Bradley Fritz, Christopher King, Yixin Chen, Alex Kronzer, Joanna Abraham, Arbi Ben Abdallah, Thomas Kannampallil, Thaddeus Budelier, Arianna Montes De Oca, Sherry Mckinnon, Bethany Tellor Pennington, Troy Wildes, Michael Avidan

2020-Current year OA Pubs

No abstract provided.

Beta-Adrenergic Antagonist Tolerance In Amyloid Cardiomyopathy, Stuart Ramsell, Carlos Arias Bermudez, Cyril Ayuk Mbeng Takem Baiyee, Brandon Rodgers, Samir Parikh, Salem Almaani, Nidhi Sharma, Samantha Lorusso, Miriam Freimer, Elyse Redder, Naresh Bumma, Ajay Vallkati, Yvonne Efebera, Rami Kahwash, Courtney M Campbell

2020-Current year OA Pubs

Background: Beta-adrenergic antagonists or blockers (BB) are a cornerstone of cardiac therapy for multiple indications. However, BB are considered relatively contraindicated in amyloid cardiomyopathy due to poor tolerance. This intolerance is hypothesized to be due to concomitant neuropathy and significant restrictive cardiomyopathy. This study analyzes the incidence and characteristics of BB tolerance in patients with amyloid cardiomyopathy.

Methods: Through a single-center retrospective chart review, patients with amyloid cardiomyopathy, confirmed by endomyocardial biopsy or technetium-99 pyrophosphate scan, were identified and clinical data was collected. Statistical methods included Chi-square test and two sample

Results: Of 135 cardiac amyloidosis patients, 27 patients (20.0%) …

Monosynaptic Targets Of Utricular Afferents In The Larval Zebrafish, Yizhen Jia, Martha W Bagnall

2020-Current year OA Pubs

The larval zebrafish acquires a repertoire of vestibular-driven behaviors that aid survival early in development. These behaviors rely mostly on the utricular otolith, which senses inertial (tilt and translational) head movements. We previously characterized the known central brainstem targets of utricular afferents using serial-section electron microscopy of a larval zebrafish brain. Here we describe the rest of the central targets of utricular afferents, focusing on the neurons whose identities are less certain in our dataset. We find that central neurons with commissural projections have a wide range of predicted directional tuning, just as in other vertebrates. In addition, somata of …

The Chasm In Percutaneous Coronary Intervention And In-Hospital Mortality Rates Among Acute Myocardial Infarction Patients In Rural And Urban Hospitals In China: A Mediation Analysis, Miao Cai, Echu Liu, Peng Bai, Nan Zhang, Siyu Wang, Wei Li, Hualiang Lin, Xiaojun Lin

2020-Current year OA Pubs

No abstract provided.

What Does It Mean To Be Affiliated With Care?: Delphi Consensus On The Definition Of "Unaffiliation" And "Specialist" In Sickle Cell Disease, Andrea E. Lamont, Lewis L. Hsu, Sara Jacobs, Robert Gibson, Marsha Treadwell, Yumei Chen, Richard Lottenberg, Kathleen Axelrod, Taniya Varughese, Cathy Melvin, Sharon Smith, Ifeanyi Beverly Chukwudozie, Julie Kanter, Sickle Cell Disease Implementation Consortium

2020-Current year OA Pubs

Accruing evidence reveals best practices for how to help individuals living with Sickle Cell Disease (SCD); yet, the implementation of these evidence-based practices in healthcare settings is lacking. The Sickle Cell Disease Implementation Consortium (SCDIC) is a national consortium that uses implementation science to identify and address barriers to care in SCD. The SCDIC seeks to understand how and why patients become unaffiliated from care and determine strategies to identify and connect patients to care. A challenge, however, is the lack of agreed-upon definition for what it means to be unaffiliated and what it means to be a "SCD expert …